Provider Demographics
NPI:1104020627
Name:WHEATON, MICHAEL OWEN (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:OWEN
Last Name:WHEATON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 MANZANITA AVE
Mailing Address - Street 2:SUITE 50
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1770
Mailing Address - Country:US
Mailing Address - Phone:916-484-7481
Mailing Address - Fax:916-484-7271
Practice Address - Street 1:4005 MANZANITA AVE
Practice Address - Street 2:SUITE 50
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-1770
Practice Address - Country:US
Practice Address - Phone:916-484-7481
Practice Address - Fax:916-484-7271
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA329151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice