Healthcare Provider Details

I. General information

NPI: 1568367712
Provider Name (Legal Business Name): WILSON DENTAL LAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 47TH AVE STE 4
SACRAMENTO CA
95824-3848
US

IV. Provider business mailing address

4500 47TH AVE STE 4
SACRAMENTO CA
95824-3848
US

V. Phone/Fax

Practice location:
  • Phone: 916-487-2236
  • Fax:
Mailing address:
  • Phone: 916-487-2236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number
License Number StateNULL

VIII. Authorized Official

Name: WILSON DUC PHAM
Title or Position: OWNER
Credential: CDT
Phone: 249-224-5335