Provider Demographics
NPI:1598010464
Name:WILSON, BENJAMIN (DMD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
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 1:1819 W 3500 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3457
Mailing Address - Country:US
Mailing Address - Phone:801-887-7264
Mailing Address - Fax:
Practice Address - Street 1:1819 W 3500 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84119-3457
Practice Address - Country:US
Practice Address - Phone:801-887-7264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8222362-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice