Provider Demographics
NPI:1124295399
Name:WILSON, CODY TIONE (DMD)
Entity type:Individual
Prefix:DR
First Name:CODY
Middle Name:TIONE
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 W HARDING AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-2596
Mailing Address - Country:US
Mailing Address - Phone:435-586-8980
Mailing Address - Fax:
Practice Address - Street 1:66 W HARDING AVE STE A
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-2596
Practice Address - Country:US
Practice Address - Phone:435-586-8980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT62422501223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics