1124053301 NPI number — DR. THOMAS F WUESTHOFF D.D.S.

Table of content: DR. THOMAS F WUESTHOFF D.D.S. (NPI 1124053301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124053301 NPI number — DR. THOMAS F WUESTHOFF D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WUESTHOFF
Provider First Name:
THOMAS
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124053301
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
176 AUBURN CT
Provider Second Line Business Mailing Address:
#5
Provider Business Mailing Address City Name:
WESTLAKE VILLAGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91362-3614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-496-4247
Provider Business Mailing Address Fax Number:
805-496-9830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 N SEE VEE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BISHOP
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93514-8130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-873-3443
Provider Business Practice Location Address Fax Number:
760-503-0205
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  37612 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: THP11576F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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