MEDICARE: WILSON LONG DDS INC

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
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1164204400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSON LONG DDS INC

Provider Business Mailing Address
First Line	:	7271 WESTMINSTER BLVD
Second Line	:
City	:	WESTMINSTER
State	:	CA
Zip	:	92683-4235
Country	:	US
Telephone Number	:	714-894-3306
Fax Number	:

Provider Business Practice Location Address
First Line	:	7271 WESTMINSTER BLVD
Second Line	:
City	:	WESTMINSTER
State	:	CA
Zip	:	92683-4235
Country	:	US
Telephone Number	:	714-894-3306
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. WILSON LONG
Credential	:	DDS
Telephone Number	:	714-894-3306

Provider Enumeration Date	:	10/20/2023
Last Update Date	:	10/20/2023

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