Healthcare Provider Details

I. General information

NPI: 1427170067
Provider Name (Legal Business Name): SHIRLEY M. WILSON D.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SUTTER ST SUITE 2439
SAN FRANCISCO CA
94108-4206
US

IV. Provider business mailing address

850 70TH AVE
OAKLAND CA
94621-3308
US

V. Phone/Fax

Practice location:
  • Phone: 415-956-6610
  • Fax: 415-956-6618
Mailing address:
  • Phone: 415-956-6610
  • Fax: 415-956-6618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: