Provider Demographics
NPI:1225108897
Name:GAETA-WILSON, LAURA MARY (DDS)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARY
Last Name:GAETA-WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 GLENCANNON ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7951
Mailing Address - Country:US
Mailing Address - Phone:707-538-0727
Mailing Address - Fax:
Practice Address - Street 1:1435 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4505
Practice Address - Country:US
Practice Address - Phone:707-571-8152
Practice Address - Fax:707-571-8332
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA351061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice