MEDICARE: KATHRYN WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	48865	CA

General Provider Information

NPI Number	:	1184781577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN WILSON

Provider Business Mailing Address
First Line	:	591 WATT AVE
Second Line	:	SUITE 100
City	:	SACRAMENTO
State	:	CA
Zip	:	95864-5027
Country	:	US
Telephone Number	:	916-481-5057
Fax Number	:

Provider Business Practice Location Address
First Line	:	591 WATT AVE
Second Line	:	SUITE 100
City	:	SACRAMENTO
State	:	CA
Zip	:	95864-5027
Country	:	US
Telephone Number	:	916-481-5057
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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Directions to “ KATHRYN WILSON ” Practice Location

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