Provider Demographics
NPI:1447368972
Name:WILSON, DONALD LEWIS (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:LEWIS
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7250 REDWOOD BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3269
Mailing Address - Country:US
Mailing Address - Phone:415-878-0240
Mailing Address - Fax:415-878-0242
Practice Address - Street 1:7250 REDWOOD BLVD STE 107
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3269
Practice Address - Country:US
Practice Address - Phone:415-878-0240
Practice Address - Fax:415-878-0242
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA478221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics