Provider Demographics
NPI:1316164056
Name:C. TODD WILSON D.D.S.P.C.
Entity type:Organization
Organization Name:C. TODD WILSON D.D.S.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAVA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-925-1566
Mailing Address - Street 1:17680 SW HANDLEY STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8795
Mailing Address - Country:US
Mailing Address - Phone:503-925-1566
Mailing Address - Fax:503-925-1576
Practice Address - Street 1:17680 SW HANDLEY STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8795
Practice Address - Country:US
Practice Address - Phone:503-925-1566
Practice Address - Fax:503-925-1576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty