Provider Demographics
NPI:1972176238
Name:HUNTER, MYLEA WILSON (DDS)
Entity type:Individual
Prefix:DR
First Name:MYLEA
Middle Name:WILSON
Last Name:HUNTER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MYLEA
Other - Middle Name:MICHELE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:700 E OCEAN BLVD UNIT 2102
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5038
Mailing Address - Country:US
Mailing Address - Phone:760-391-3342
Mailing Address - Fax:
Practice Address - Street 1:9228 RESIDENCIA
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-9066
Practice Address - Country:US
Practice Address - Phone:760-391-3342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105691122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA105691OtherDENTAL BOARD OF CALIFORNIA