Provider Demographics
NPI:1285645309
Name:WILSON, WILLIAM GEORGE (DDS)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GEORGE
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 1:1604 FORD AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4655
Mailing Address - Country:US
Mailing Address - Phone:209-579-5444
Mailing Address - Fax:209-579-5445
Practice Address - Street 1:1604 FORD AVE STE 12
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4655
Practice Address - Country:US
Practice Address - Phone:209-579-5444
Practice Address - Fax:209-579-5445
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA329171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB32917-01OtherCA MEDI-CAL DENTAL PROG
CA163-84-0062OtherADA #