Provider Demographics
NPI:1881816957
Name:DAVID R. WYNDHAMSMITH, A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:DAVID R. WYNDHAMSMITH, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:PASADENA DENTAL CARE
Other - Org Type:Other Name
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
Mailing Address - Country:US
Mailing Address - Phone:626-795-9328
Mailing Address - Fax:626-795-3763
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
Practice Address - Country:US
Practice Address - Phone:626-795-9328
Practice Address - Fax:626-795-3763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty