Provider Demographics
NPI:1134126923
Name:PETER WYLAN, D.D.S., INC
Entity Type:Organization
Organization Name:PETER WYLAN, D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.D.S
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:NMI
Authorized Official - Last Name:WYLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-925-3765
Mailing Address - Street 1:10318 ROSECRANS AVE
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-2702
Mailing Address - Country:US
Mailing Address - Phone:562-925-3765
Mailing Address - Fax:562-920-2493
Practice Address - Street 1:10318 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-2702
Practice Address - Country:US
Practice Address - Phone:562-925-3765
Practice Address - Fax:562-920-2493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14411122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty