Provider Demographics
NPI:1487155867
Name:WILSON DENTAL PC
Entity type:Organization
Organization Name:WILSON DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-228-8571
Mailing Address - Street 1:205 COMMUNITY BLVD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2659
Mailing Address - Country:US
Mailing Address - Phone:276-228-8571
Mailing Address - Fax:276-228-8571
Practice Address - Street 1:205 COMMUNITY BLVD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2659
Practice Address - Country:US
Practice Address - Phone:276-228-8571
Practice Address - Fax:276-228-8571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014148021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1285014019OtherPERSONAL NPI