Provider Demographics
NPI:1386977247
Name:WADE, MONICA LATRICE
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:LATRICE
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 VIANA DR.
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550
Mailing Address - Country:US
Mailing Address - Phone:661-267-0793
Mailing Address - Fax:
Practice Address - Street 1:44558 10TH STREET WEST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:310-820-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68982126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant