Provider Demographics
NPI:1699726414
Name:WILSON, THOMAS G (DDS)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
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 1:8515 DOUGLAS AVE
Mailing Address - Street 2:STE 26
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50322
Mailing Address - Country:US
Mailing Address - Phone:515-278-2333
Mailing Address - Fax:515-278-5492
Practice Address - Street 1:8515 DOUGLAS AVE
Practice Address - Street 2:STE 26
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50322
Practice Address - Country:US
Practice Address - Phone:515-278-2333
Practice Address - Fax:515-278-5492
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA72611223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0221XDental ProvidersDentistPediatric Dentistry
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1086108Medicaid