Provider Demographics
NPI:1457435026
Name:WILSON, JOE (DDS)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
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 1:4185 CENTENNIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3767
Mailing Address - Country:US
Mailing Address - Phone:719-590-8895
Mailing Address - Fax:719-590-1078
Practice Address - Street 1:4185 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3767
Practice Address - Country:US
Practice Address - Phone:719-590-8895
Practice Address - Fax:719-590-1078
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1058791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice