Provider Demographics
NPI:1912350364
Name:WILEY M ELICK, DDS, INC
Entity Type:Organization
Organization Name:WILEY M ELICK, DDS, INC
Other - Org Name:KIDS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-582-0238
Mailing Address - Street 1:833 GREENFIELD AVE
Mailing Address - Street 2:#105
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3672
Mailing Address - Country:US
Mailing Address - Phone:559-582-0238
Mailing Address - Fax:559-582-1365
Practice Address - Street 1:833 GREENFIELD AVE
Practice Address - Street 2:#105
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3672
Practice Address - Country:US
Practice Address - Phone:559-582-0238
Practice Address - Fax:559-582-1365
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILEY M ELICK, DDS, INC.,DBA KIDS DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21245122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty