Provider Demographics
NPI:1386717213
Name:WILSON, JOHN THORNTON (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THORNTON
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 1:5716 N MARCLIFFE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-2058
Mailing Address - Country:US
Mailing Address - Phone:208-375-5631
Mailing Address - Fax:208-323-8538
Practice Address - Street 1:10497 W GARVERDALE CT
Practice Address - Street 2:SUITE 107
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5407
Practice Address - Country:US
Practice Address - Phone:208-375-5720
Practice Address - Fax:208-323-8538
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-14491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice