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General NPI Number Information
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NPI Number | 1003657669
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Entity Type | Organization
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Legal Business Name | WILSON DMD A PROFESSIONAL DENTAL CORPORATION
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Dates
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Enumeration Date | 06/05/2024
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Last Update Date | 07/24/2024
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Provider Practice Location Address
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Address Line | 933 SHASTA ST
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City | YUBA CITY
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State | CA
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Zip | 95991-4114
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Country | US
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Telephone | 530-671-1770
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Fax |
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Provider Business Mailing Address
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Address Line | 933 SHASTA ST
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City | YUBA CITY
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State | CA
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Zip | 95991-4114
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Country | US
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Telephone | 530-671-1770
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Fax |
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Authorized Official
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Title or Position | COORDINATOR
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Name | KRYSTAL CASTILLO
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Credential |
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Telephone | 972-689-8630
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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