Provider Demographics
NPI:1811337553
Name:WILSON, SHAWN KEVIN (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:KEVIN
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 1:3110 CHURN CREEK RD
Mailing Address - Street 2:
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 RD
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
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0325181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1811337553OtherINDIVIDUAL NPI
CA1477636280OtherCORPORATE NPI