Provider Demographics
NPI:1518385756
Name:WILSON, KADIN K (DMD)
Entity Type:Individual
Prefix:
First Name:KADIN
Middle Name:K
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3476
Mailing Address - Country:US
Mailing Address - Phone:619-205-1950
Mailing Address - Fax:619-205-1951
Practice Address - Street 1:3725 W 4100 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5411
Practice Address - Country:US
Practice Address - Phone:801-969-8881
Practice Address - Fax:801-969-8889
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9719126-99221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty