Provider Demographics
NPI:1083632368
Name:WISTROM, DAVID WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:WISTROM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 COMMERCIAL WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1819
Mailing Address - Country:US
Mailing Address - Phone:831-464-5409
Mailing Address - Fax:831-464-5415
Practice Address - Street 1:1830 COMMERCIAL WAY
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1819
Practice Address - Country:US
Practice Address - Phone:831-464-5409
Practice Address - Fax:831-464-5415
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA427851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice