Provider Demographics
NPI:1164204400
Name:WILSON LONG DDS INC
Entity Type:Organization
Organization Name:WILSON LONG DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-894-3306
Mailing Address - Street 1:7271 WESTMINSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-4235
Mailing Address - Country:US
Mailing Address - Phone:714-894-3306
Mailing Address - Fax:
Practice Address - Street 1:7271 WESTMINSTER BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-4235
Practice Address - Country:US
Practice Address - Phone:714-894-3306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental