MEDICARE: NEIL S WILENSKY 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	122300000X	Dentist	019990	CA

General Provider Information

NPI Number	:	1669580486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEIL S WILENSKY DDS INC

Provider Business Mailing Address
First Line	:	895 RIVER DRIVE
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-5441
Country	:	US
Telephone Number	:	707-961-4270
Fax Number	:	707-961-4275

Provider Business Practice Location Address
First Line	:	895 RIVER DRIVE
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-5441
Country	:	US
Telephone Number	:	707-961-4270
Fax Number	:	707-961-4275

Authorized Official
Title or Position	:	OWNER PRESIDENT OF CORPORATION
Name	:	DR. NEIL STEVEN WILENSKY
Credential	:	DDS
Telephone Number	:	707-961-4270

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	08/22/2020

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