Provider Demographics
NPI:1679726335
Name:WONNACOTT, MICHAEL DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:WONNACOTT
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 1:2131 CAPITOL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5755
Mailing Address - Country:US
Mailing Address - Phone:916-446-6625
Mailing Address - Fax:916-446-6636
Practice Address - Street 1:2131 CAPITOL AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816
Practice Address - Country:US
Practice Address - Phone:916-446-6625
Practice Address - Fax:916-446-6636
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA504031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice