Provider Demographics
NPI:1346351525
Name:WILSON, DAN R (DDS)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:R
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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:POMEROY
Mailing Address - State:WA
Mailing Address - Zip Code:99347-0099
Mailing Address - Country:US
Mailing Address - Phone:509-843-3495
Mailing Address - Fax:509-843-3496
Practice Address - Street 1:813 1/2 COLUMBIA STREET
Practice Address - Street 2:813 1/2 COLUMBIA #99
Practice Address - City:POMEROY
Practice Address - State:WA
Practice Address - Zip Code:99347
Practice Address - Country:US
Practice Address - Phone:509-834-3495
Practice Address - Fax:509-843-3496
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA59741223G0001X
IDD18621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2074241Medicaid