Provider Demographics
NPI:1154773489
Name:DAVID G WILSON DMD LLC
Entity type:Organization
Organization Name:DAVID G WILSON DMD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-850-8119
Mailing Address - Street 1:1372 N SUSQUEHANNA TRL STE 140
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-8973
Mailing Address - Country:US
Mailing Address - Phone:570-743-8119
Mailing Address - Fax:570-743-2009
Practice Address - Street 1:1372 N SUSQUEHANNA TRL STE 140
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-8973
Practice Address - Country:US
Practice Address - Phone:570-743-8119
Practice Address - Fax:570-743-2009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVID G WILSON DMD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-11
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019605L122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7556450001OtherMEDICARE DME PTAN NUMBER