Healthcare Provider Details

I. General information

NPI: 1518308105
Provider Name (Legal Business Name): WILSON SHUAIWEN JING DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43000 MIDWAY DR MARINE CORP RECRUITING STATION BLDG 595
SAN DIEGO CA
92140-4500
US

IV. Provider business mailing address

2848 DURHAM RIDGE PL
SAN DIEGO CA
92110-4862
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-4009
  • Fax:
Mailing address:
  • Phone: 601-750-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number62950
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number62950
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10983
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberM12345678
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: