Healthcare Provider Details

I. General information

NPI: 1447772124
Provider Name (Legal Business Name): KIMBERLY D WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4941 OLIVEHURST AVE
OLIVEHURST CA
95961-4225
US

IV. Provider business mailing address

935 MARKET ST
YUBA CITY CA
95991-4217
US

V. Phone/Fax

Practice location:
  • Phone: 530-743-4614
  • Fax:
Mailing address:
  • Phone: 916-292-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number24554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: