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NPI Code Detail

MEDICARE: DR. DAVID WILLIAM WISTROM DDS

MEDICARE: DR. DAVID WILLIAM WISTROM DDS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry42785CA

General Provider Information

NPI Number : 1083632368
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DAVID WILLIAM WISTROM DDS
Provider Business Mailing Address
First Line : 1830 COMMERCIAL WAY
Second Line :
City : SANTA CRUZ
State : CA
Zip : 95065-1819
Country : US
Telephone Number : 831-464-5409
Fax Number : 831-464-5415
Provider Business Practice Location Address
First Line : 1830 COMMERCIAL WAY
Second Line :
City : SANTA CRUZ
State : CA
Zip : 95065-1819
Country : US
Telephone Number : 831-464-5409
Fax Number : 831-464-5415
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/17/2006
Last Update Date : 08/25/2025

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