Provider Demographics
NPI:1992355077
Name:PRESTON WILFONG, KARLA LOIS (EPDH)
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:LOIS
Last Name:PRESTON WILFONG
Suffix:
Gender:F
Credentials:EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 LUPINE LN
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8507
Mailing Address - Country:US
Mailing Address - Phone:541-580-7244
Mailing Address - Fax:
Practice Address - Street 1:1600 GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8700
Practice Address - Country:US
Practice Address - Phone:541-677-4818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4521124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist