Provider Demographics
NPI:1194148312
Name:CRISTIN C WILSON DDS
Entity type:Organization
Organization Name:CRISTIN C WILSON DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:402-492-9476
Mailing Address - Street 1:11717 BURT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-1500
Mailing Address - Country:US
Mailing Address - Phone:402-492-9476
Mailing Address - Fax:402-492-9838
Practice Address - Street 1:11717 BURT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-1500
Practice Address - Country:US
Practice Address - Phone:402-492-9476
Practice Address - Fax:402-492-9838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE57401223G0001X
NE71131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026100400Medicaid