Provider Demographics
NPI:1568717809
Name:SEJERA-WAGNER, KAYLA LEE (RDHAP)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:LEE
Last Name:SEJERA-WAGNER
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 872
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-0872
Mailing Address - Country:US
Mailing Address - Phone:805-748-3364
Mailing Address - Fax:805-489-7368
Practice Address - Street 1:1424 NOYES RD
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-5049
Practice Address - Country:US
Practice Address - Phone:805-748-3364
Practice Address - Fax:805-489-7368
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP 418124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist