Provider Demographics
NPI:1326034661
Name:WILSON, JAMES C (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
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 1:19 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-2772
Mailing Address - Country:US
Mailing Address - Phone:419-447-9541
Mailing Address - Fax:419-447-1223
Practice Address - Street 1:19 W MARKET ST
Practice Address - Street 2:SUITE A
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2772
Practice Address - Country:US
Practice Address - Phone:419-447-9541
Practice Address - Fax:419-447-1223
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300166101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0568827Medicaid