Healthcare Provider Details

I. General information

NPI: 1255829198
Provider Name (Legal Business Name): KAITLYN MICHELLE WILSON DA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6323 N FRESNO ST STE 101
FRESNO CA
93710-5282
US

IV. Provider business mailing address

6323 N FRESNO ST STE 101
FRESNO CA
93710-5282
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-2307
  • Fax:
Mailing address:
  • Phone: 559-439-2307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRA86061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: