Provider Demographics
NPI:1184006074
Name:JOHN WILSON DDS, PLLC
Entity Type:Organization
Organization Name:JOHN WILSON DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-949-8147
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:CONNELL
Mailing Address - State:WA
Mailing Address - Zip Code:99326-0327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 PINE ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-9327
Practice Address - Country:US
Practice Address - Phone:509-949-8147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty