Provider Demographics
NPI:1508878455
Name:WEXLEY, VICTORIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:
Last Name:WEXLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 N FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-7261
Mailing Address - Country:US
Mailing Address - Phone:323-655-3933
Mailing Address - Fax:323-655-9725
Practice Address - Street 1:739 N FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-7261
Practice Address - Country:US
Practice Address - Phone:323-655-3933
Practice Address - Fax:323-655-9725
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420182081P2900X
CAD420181223X2210X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherEIN/SSN
U90787Medicare UPIN
CA6224410001Medicare NSC
CAD42018AMedicare PIN