=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538416441
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN KYLE ODENWALDER DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2012
-----------------------------------------------------
Last Update Date | 04/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3935 MISSION AVE STE 9
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92058-7802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-439-5515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3935 MISSION AVE STE 9
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92058-7802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-439-5515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DDS10299
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8352806-9922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------