Provider Demographics
NPI:1104042761
Name:WILSON, RICHARD LYMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LYMAN
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:PO BOX 737
Mailing Address - Street 2:SUHC
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137-0737
Mailing Address - Country:US
Mailing Address - Phone:970-563-4581
Mailing Address - Fax:970-563-4581
Practice Address - Street 1:123 WEEMINUCHE AVE
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137
Practice Address - Country:US
Practice Address - Phone:970-563-4581
Practice Address - Fax:970-563-4581
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO7355122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist