Provider Demographics
NPI:1821435736
Name:WEDMORE, AIMEE ELIZABETH (BS)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:ELIZABETH
Last Name:WEDMORE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33099 LORIMER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-6032
Mailing Address - Country:US
Mailing Address - Phone:951-265-7918
Mailing Address - Fax:
Practice Address - Street 1:33099 LORIMER ST
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-6032
Practice Address - Country:US
Practice Address - Phone:951-265-7918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27041124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist