Provider Demographics
NPI:1366582454
Name:WILSON, TIMOTHY A (DDS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
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 1:526 S TONOPAH DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4043
Mailing Address - Country:US
Mailing Address - Phone:702-291-2031
Mailing Address - Fax:702-366-1483
Practice Address - Street 1:169 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5320
Practice Address - Country:US
Practice Address - Phone:702-384-1010
Practice Address - Fax:702-438-8424
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4522T122300000X
NVS6-1421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV10052976Medicaid
NV1366582454Medicaid
NV100506669Medicaid