Provider Demographics
NPI:1710540364
Name:REED, LILIAN WAGAS
Entity Type:Individual
Prefix:
First Name:LILIAN
Middle Name:WAGAS
Last Name:REED
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 1:30035 HAUN RD
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-6805
Mailing Address - Country:US
Mailing Address - Phone:951-566-9090
Mailing Address - Fax:
Practice Address - Street 1:671 DOVE DR
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-1955
Practice Address - Country:US
Practice Address - Phone:909-255-5670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA92660126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDA92660Medicaid