Provider Demographics
NPI:1043368103
Name:WASILESKI, DINA MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DINA
Middle Name:MARIE
Last Name:WASILESKI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:DINA
Other - Middle Name:WASILESKI
Other - Last Name:SCORDAKIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD, RN, BS
Mailing Address - Street 1:9216 KIEFER BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-5418
Mailing Address - Country:US
Mailing Address - Phone:916-363-2374
Mailing Address - Fax:916-363-5223
Practice Address - Street 1:9216 KIEFER BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-5418
Practice Address - Country:US
Practice Address - Phone:916-363-2374
Practice Address - Fax:916-363-5223
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA377521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice