Provider Demographics
NPI:1508088675
Name:DAVID R. WYNDHAMSMITH, A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:DAVID R. WYNDHAMSMITH, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:PASADENA MEDICAL/DENTAL SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WYNDHAMSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-795-9328
Mailing Address - Street 1:1092 E GREEN ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2506
Mailing Address - Country:US
Mailing Address - Phone:626-395-5140
Mailing Address - Fax:626-395-5144
Practice Address - Street 1:1092 E GREEN ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2506
Practice Address - Country:US
Practice Address - Phone:626-395-5140
Practice Address - Fax:626-395-5144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA461951223E0200X
CA411221223P0300X
CA493121223S0112X
CA375191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty