Provider Demographics
NPI:1124231261
Name:WILSON, DAVID EARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EARL
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 1:2145 ELKHORN DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-1204
Mailing Address - Country:US
Mailing Address - Phone:541-653-9188
Mailing Address - Fax:541-345-8037
Practice Address - Street 1:3335 S HOLMES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7981
Practice Address - Country:US
Practice Address - Phone:208-524-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD85411223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics