Provider Demographics
NPI:1386218824
Name:HEATHER WILSON DDS LLC
Entity Type:Organization
Organization Name:HEATHER WILSON DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-234-2930
Mailing Address - Street 1:3111 S KIMBROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5011
Mailing Address - Country:US
Mailing Address - Phone:417-887-5661
Mailing Address - Fax:
Practice Address - Street 1:3111 S KIMBROUGH AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5011
Practice Address - Country:US
Practice Address - Phone:417-887-5661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty