Provider Demographics
NPI:1487726055
Name:WILSON, MONTY C (DDS)
Entity type:Individual
Prefix:DR
First Name:MONTY
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1122 E LINCOLN AVE
Mailing Address - Street 2:STE. 105
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-1907
Mailing Address - Country:US
Mailing Address - Phone:714-998-7450
Mailing Address - Fax:714-998-2857
Practice Address - Street 1:1122 E LINCOLN AVE
Practice Address - Street 2:STE. 105
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1907
Practice Address - Country:US
Practice Address - Phone:714-998-7450
Practice Address - Fax:714-998-2857
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA473391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU99694Medicare UPIN