Provider Demographics
NPI:1578736013
Name:WILSON, TYLER M (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 S COLLEGE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1304
Mailing Address - Country:US
Mailing Address - Phone:805-925-1440
Mailing Address - Fax:
Practice Address - Street 1:2151 S COLLEGE DR STE 104
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1304
Practice Address - Country:US
Practice Address - Phone:805-925-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA532951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery