Provider Demographics
NPI:1093111270
Name:DENTAL STUDIO ON 30TH STREET PC
Entity Type:Organization
Organization Name:DENTAL STUDIO ON 30TH STREET PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD, LLC
Authorized Official - Phone:505-360-9592
Mailing Address - Street 1:2401 E 30TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8939
Mailing Address - Country:US
Mailing Address - Phone:505-325-8858
Mailing Address - Fax:
Practice Address - Street 1:2401 E 30TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8939
Practice Address - Country:US
Practice Address - Phone:505-325-8858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD33991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty