Provider Demographics
NPI:1285642066
Name:WISHAN, MELVYN S (DDS, MDS)
Entity Type:Individual
Prefix:
First Name:MELVYN
Middle Name:S
Last Name:WISHAN
Suffix:
Gender:M
Credentials:DDS, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 N ROXBURY DR
Mailing Address - Street 2:SUITE 404
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-5027
Mailing Address - Country:US
Mailing Address - Phone:310-274-8587
Mailing Address - Fax:310-274-6936
Practice Address - Street 1:435 N ROXBURY DR
Practice Address - Street 2:SUITE 404
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5027
Practice Address - Country:US
Practice Address - Phone:310-274-8587
Practice Address - Fax:310-274-6936
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA160781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU05403Medicare UPIN
CAD16078Medicare ID - Type UnspecifiedMEDICARE IDENTIFIER