MEDICARE: MRS. LAURA MARY GAETA-WILSON DDS

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	1223G0001X	General Practice Dentistry	35106	CA

General Provider Information

NPI Number	:	1225108897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA MARY GAETA-WILSON DDS

Provider Business Mailing Address
First Line	:	4850 GLENCANNON ST
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7951
Country	:	US
Telephone Number	:	707-538-0727
Fax Number	:

Provider Business Practice Location Address
First Line	:	1435 MONTGOMERY DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4505
Country	:	US
Telephone Number	:	707-571-8152
Fax Number	:	707-571-8332

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

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/08/2007

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