Provider Demographics
NPI:1720452600
Name:WICK, MAGNA ISABELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAGNA
Middle Name:ISABELLE
Last Name:WICK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CALLE ALCALA
Mailing Address - Street 2:COLLEGE PARK APT. 1702
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-3908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 CARR 1
Practice Address - Street 2:SUITE 12 CENTRO COMERCIAL BAIROA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-1591
Practice Address - Country:US
Practice Address - Phone:787-746-6660
Practice Address - Fax:787-743-5255
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR32141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice