Provider Demographics
NPI:1114063443
Name:RC & SA WILSON DDS PC
Entity Type:Organization
Organization Name:RC & SA WILSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-498-8804
Mailing Address - Street 1:13215 BIRCH DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-5431
Mailing Address - Country:US
Mailing Address - Phone:402-498-8804
Mailing Address - Fax:402-498-8838
Practice Address - Street 1:13215 BIRCH DR
Practice Address - Street 2:SUITE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-5431
Practice Address - Country:US
Practice Address - Phone:402-498-8804
Practice Address - Fax:402-498-8838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE50601223G0001X
NE52481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty