Provider Demographics
NPI:1255829198
Name:WILSON, KAITLYN MICHELLE (DA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6323 N FRESNO ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5282
Mailing Address - Country:US
Mailing Address - Phone:559-439-2307
Mailing Address - Fax:
Practice Address - Street 1:6323 N FRESNO ST STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5282
Practice Address - Country:US
Practice Address - Phone:559-439-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARA86061126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant