=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467852269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILSON DENTISTRY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2014
-----------------------------------------------------
Last Update Date | 12/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1063 N. D ST
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-233-7250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1063 N D ST
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92410-3539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-233-7250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | KAREN L BUTLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 607-238-1280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 62234
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------