Provider Demographics
NPI:1093894925
Name:WILEY M ELICK DDS INC
Entity Type:Organization
Organization Name:WILEY M ELICK DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-582-0238
Mailing Address - Street 1:460 N GREENFIELD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230
Mailing Address - Country:US
Mailing Address - Phone:559-582-0238
Mailing Address - Fax:559-582-9341
Practice Address - Street 1:460 N GREENFIELD
Practice Address - Street 2:SUITE 9
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230
Practice Address - Country:US
Practice Address - Phone:559-582-0238
Practice Address - Fax:559-582-9341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2124501Medicaid