Provider Demographics
NPI:1467947572
Name:TAM, WILSON
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7995 CIVITA BLVD APT 312
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-5212
Mailing Address - Country:US
Mailing Address - Phone:415-472-9834
Mailing Address - Fax:
Practice Address - Street 1:110 TOWN CENTER PKWY STE A
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-5801
Practice Address - Country:US
Practice Address - Phone:619-396-2477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-30
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0613121223P0221X
NY390200000X
CA1033581223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program