Provider Demographics
NPI:1538416441
Name:ODENWALDER, SEAN KYLE (DMD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:KYLE
Last Name:ODENWALDER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3935 MISSION AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-7802
Mailing Address - Country:US
Mailing Address - Phone:760-439-5515
Mailing Address - Fax:
Practice Address - Street 1:3935 MISSION AVE STE 9
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-7802
Practice Address - Country:US
Practice Address - Phone:760-439-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS10299122300000X
UT8352806-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist