Provider Demographics
NPI:1205844230
Name:WILSON, RUSSELL CLAYTON (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:CLAYTON
Last Name:WILSON
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 1:2738 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4332
Mailing Address - Country:US
Mailing Address - Phone:559-732-3972
Mailing Address - Fax:559-732-1506
Practice Address - Street 1:2738 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4332
Practice Address - Country:US
Practice Address - Phone:559-732-3972
Practice Address - Fax:559-732-1506
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA463461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice