Provider Demographics
NPI:1356467955
Name:MYERS, WILSON JR (DDS)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:MYERS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:HACIENDA
Other - Middle Name:
Other - Last Name:DENTAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5674 STONERIDGE DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8500
Mailing Address - Country:US
Mailing Address - Phone:925-734-0104
Mailing Address - Fax:
Practice Address - Street 1:5674 STONERIDGE DR
Practice Address - Street 2:STE 111
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-8500
Practice Address - Country:US
Practice Address - Phone:925-734-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA248401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice