Provider Demographics
NPI:1255842720
Name:WILD, SHAWN ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:SHAWN
Middle Name:ELIZABETH
Last Name:WILD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 FORD LN
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-5500
Mailing Address - Country:US
Mailing Address - Phone:562-743-4126
Mailing Address - Fax:
Practice Address - Street 1:10602 CHAPMAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-3147
Practice Address - Country:US
Practice Address - Phone:714-537-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18779124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist