Provider Demographics
NPI:1992708952
Name:WILSON, DAVID G (DMD, LLC)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:WILSON
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Gender:M
Credentials:DMD, LLC
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Mailing Address - Street 1:1372 N SUSQUEHANNA TRL
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-8971
Mailing Address - Country:US
Mailing Address - Phone:570-743-8119
Mailing Address - Fax:570-743-2009
Practice Address - Street 1:1372 N SUSQUEHANNA TRL
Practice Address - Street 2:SUITE 140
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-8971
Practice Address - Country:US
Practice Address - Phone:570-743-8119
Practice Address - Fax:570-743-2009
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2013-12-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PADS019605-L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics