Provider Demographics
NPI:1164507489
Name:WILSON DENTAL CLINIC, PLC
Entity Type:Organization
Organization Name:WILSON DENTAL CLINIC, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:641-585-5431
Mailing Address - Street 1:145 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50436-1615
Mailing Address - Country:US
Mailing Address - Phone:641-585-5431
Mailing Address - Fax:641-585-5435
Practice Address - Street 1:145 N CLARK ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:IA
Practice Address - Zip Code:50436-1615
Practice Address - Country:US
Practice Address - Phone:641-585-5431
Practice Address - Fax:641-585-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA56601223G0001X
IA78421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA11965OtherBC/BS OF IA FEDERAL PROGR
IA0119651Medicaid
IA0253963Medicaid
IA48855OtherBC/BS OF IA FEDERAL PROGR