Provider Demographics
NPI:1487788212
Name:WILSON, REYNALDO BENNETT (DDS)
Entity type:Individual
Prefix:DR
First Name:REYNALDO
Middle Name:BENNETT
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 SANDHURST DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-6881
Mailing Address - Country:US
Mailing Address - Phone:707-554-2645
Mailing Address - Fax:
Practice Address - Street 1:265 16TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3214
Practice Address - Country:US
Practice Address - Phone:510-233-6515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA334051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice