Provider Demographics
NPI:1356332530
Name:WILSON, W RON (DDS)
Entity Type:Individual
Prefix:MR
First Name:W
Middle Name:RON
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 1:8 GOVERNORS LN
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1990
Mailing Address - Country:US
Mailing Address - Phone:530-877-7661
Mailing Address - Fax:530-877-7702
Practice Address - Street 1:8 GOVERNORS LN
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1990
Practice Address - Country:US
Practice Address - Phone:530-877-7661
Practice Address - Fax:530-877-7702
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA464461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADS0464460Medicare ID - Type Unspecified