Provider Demographics
NPI:1376857771
Name:WINGO, AUDREY LEE
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:LEE
Last Name:WINGO
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 1:6484 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:CA
Mailing Address - Zip Code:95018-9402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1513 FREMONT BLVD # E-2
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-4319
Practice Address - Country:US
Practice Address - Phone:831-324-4492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA594751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice