Provider Demographics
NPI:1043216807
Name:WILSON, JACK ANTHONY (RDHAP)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ANTHONY
Last Name:WILSON
Suffix:
Gender:M
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2654 STACEY WAY
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-7760
Mailing Address - Country:US
Mailing Address - Phone:559-289-8293
Mailing Address - Fax:
Practice Address - Street 1:2654 STACEY WAY
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-7760
Practice Address - Country:US
Practice Address - Phone:559-289-8293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP 299124Q00000X
CARDH 17937124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA299OtherREGISTERED DENTAL HYGIENIST IN ALTERNATIVE PRACTICE
CA299OtherREGISTERED DENTAL HYGIENIST IN ALTERNATIVE PRACTICE