Provider Demographics
NPI:1306894498
Name:WILSON, RENAE L (DDS)
Entity type:Individual
Prefix:
First Name:RENAE
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 W MADISON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-3405
Mailing Address - Country:US
Mailing Address - Phone:619-588-2420
Mailing Address - Fax:619-588-1324
Practice Address - Street 1:275 W MADISON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3405
Practice Address - Country:US
Practice Address - Phone:619-588-2420
Practice Address - Fax:619-588-1324
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA399131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice