Provider Demographics
NPI:1346521028
Name:WILSON, DUSTIN C (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 W STADIUM BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-4752
Mailing Address - Country:US
Mailing Address - Phone:573-634-5122
Mailing Address - Fax:
Practice Address - Street 1:748 W STADIUM BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-4752
Practice Address - Country:US
Practice Address - Phone:573-634-5122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090132461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics