Provider Demographics
NPI:1013192913
Name:SPENCER G WILSON DDS PC
Entity Type:Organization
Organization Name:SPENCER G WILSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-279-5949
Mailing Address - Street 1:1355 S HIGLEY RD STE 106
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4799
Mailing Address - Country:US
Mailing Address - Phone:480-279-5949
Mailing Address - Fax:
Practice Address - Street 1:1355 S HIGLEY RD STE 106
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4799
Practice Address - Country:US
Practice Address - Phone:480-279-5949
Practice Address - Fax:480-279-0784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD00207391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ502262Medicaid