Provider Demographics
NPI:1063821429
Name:WILSON, MANDI LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANDI
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13203 HADLEY ST STE 105
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90601-4530
Mailing Address - Country:US
Mailing Address - Phone:562-696-6555
Mailing Address - Fax:
Practice Address - Street 1:13203 HADLEY ST STE 105
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90601-4530
Practice Address - Country:US
Practice Address - Phone:562-696-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2014-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63484122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist