1902107394 NPI number — DR. WILLIAM DAVID WICKLAND DDS

Table of content: DR. WILLIAM DAVID WICKLAND DDS (NPI 1902107394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902107394 NPI number — DR. WILLIAM DAVID WICKLAND DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKLAND
Provider First Name:
WILLIAM
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902107394
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 998
Provider Second Line Business Mailing Address:
8233 RAINBOW AVE
Provider Business Mailing Address City Name:
KINGS BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96143-0998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-250-5205
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8233 RAINBOW AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGS BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-250-5205
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  27710 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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