=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568717809
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLA LEE SEJERA-WAGNER RDHAP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2012
-----------------------------------------------------
Last Update Date | 07/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1424 NOYES RD
-----------------------------------------------------
City | ARROYO GRANDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93420-5049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-748-3364
-----------------------------------------------------
Fax | 805-489-7368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 872
-----------------------------------------------------
City | PISMO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93448-0872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-748-3364
-----------------------------------------------------
Fax | 805-489-7368
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | RDHAP 418
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------