Provider Demographics
NPI:1477636280
Name:SHAWN K WILSON DDS INC
Entity Type:Organization
Organization Name:SHAWN K WILSON DDS INC
Other - Org Name:SHAWN K WILSON DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-222-0515
Mailing Address - Street 1:3110 CHURN CREEK ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002
Mailing Address - Country:US
Mailing Address - Phone:530-222-0515
Mailing Address - Fax:530-222-1623
Practice Address - Street 1:3110 CHURN CREEK ROAD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002
Practice Address - Country:US
Practice Address - Phone:530-222-0515
Practice Address - Fax:530-222-1623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA032518122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty