Provider Demographics
NPI:1285635946
Name:WILSON, GARY ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALAN
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:HIGHWAY 264, MP 388
Mailing Address - Street 2:
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042
Mailing Address - Country:US
Mailing Address - Phone:928-737-6000
Mailing Address - Fax:928-737-6168
Practice Address - Street 1:HIGHWAY 264, MILEPOST 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042-6042
Practice Address - Country:US
Practice Address - Phone:928-737-6000
Practice Address - Fax:928-737-6168
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1043571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice