Provider Demographics
NPI:1396817698
Name:WILSON, WENDI L
Entity Type:Individual
Prefix:DR
First Name:WENDI
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2151
Mailing Address - Country:US
Mailing Address - Phone:510-841-1128
Mailing Address - Fax:510-841-7920
Practice Address - Street 1:2930 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2151
Practice Address - Country:US
Practice Address - Phone:510-841-1128
Practice Address - Fax:510-841-7920
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA270871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice