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General NPI Number Information
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NPI Number | 1255842720
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Entity Type | Individual
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Provider Name | MRS. SHAWN ELIZABETH WILD
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Gender | Female
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Dates
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Enumeration Date | 10/23/2017
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Last Update Date | 10/23/2017
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Provider Practice Location Address
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Address Line | 10602 CHAPMAN AVE STE 200
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City | GARDEN GROVE
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State | CA
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Zip | 92840-3147
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Country | US
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Telephone | 714-537-7900
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Fax |
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Provider Business Mailing Address
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Address Line | 2000 FORD LN
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City | PLACENTIA
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State | CA
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Zip | 92870-5500
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Country | US
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Telephone | 562-743-4126
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 18779
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License Number State | CA
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