Provider Demographics
NPI:1497312888
Name:WILSON PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:WILSON PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MANDI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-330-4661
Mailing Address - Street 1:21020 PACIFIC CITY CIR UNIT 2423
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-8516
Mailing Address - Country:US
Mailing Address - Phone:903-330-4661
Mailing Address - Fax:
Practice Address - Street 1:31103 RANCHO VIEJO RD STE D5
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1759
Practice Address - Country:US
Practice Address - Phone:949-661-3380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental