=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730324757
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELVA SOSA WYATT DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2008
-----------------------------------------------------
Last Update Date | 12/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8004 HAVEN AVE STE. 100
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-3047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-483-6851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16646 QUAIL HOLLOW WAY
-----------------------------------------------------
City | CHINO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91709-7440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-606-9700
-----------------------------------------------------
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 | 43508
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------