Healthcare Provider Details

I. General information

NPI: 1457411258
Provider Name (Legal Business Name): WILSON AND NOVOTNY DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9310 CARMEL MOUNTAIN RD SUITE D
SAN DIEGO CA
92129-2158
US

IV. Provider business mailing address

9310 CARMEL MOUNTAIN ROAD SUITE D
SAN DIEGO CA
92129-2158
US

V. Phone/Fax

Practice location:
  • Phone: 858-484-4880
  • Fax:
Mailing address:
  • Phone: 858-484-4880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number32157
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number32204
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number32204
License Number StateCA

VIII. Authorized Official

Name: DR. RICHARD KENNY WILSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 858-484-4880