Provider Demographics
NPI:1124141536
Name:WILSON, GEORGE M (DDS)
Entity type:Individual
Prefix:MR
First Name:GEORGE
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 1:380 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-3323
Mailing Address - Country:US
Mailing Address - Phone:559-781-9117
Mailing Address - Fax:559-781-2819
Practice Address - Street 1:380 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3323
Practice Address - Country:US
Practice Address - Phone:559-781-9117
Practice Address - Fax:559-781-2819
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry