Provider Demographics
NPI:1952618142
Name:WILSON, SPENCER WILLIAM
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:WILLIAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 SHASTA ST
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-4114
Mailing Address - Country:US
Mailing Address - Phone:530-671-1770
Mailing Address - Fax:530-671-4778
Practice Address - Street 1:933 SHASTA ST
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-4114
Practice Address - Country:US
Practice Address - Phone:915-744-6083
Practice Address - Fax:915-744-2027
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX258781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice