Provider Demographics
NPI:1417246562
Name:DR. JOSEPH A. WILSON DMD, MSD, LLC
Entity Type:Organization
Organization Name:DR. JOSEPH A. WILSON DMD, MSD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MSD LLC
Authorized Official - Phone:702-469-3590
Mailing Address - Street 1:4760 N BUTLER AVESUITE A
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:702-469-3590
Mailing Address - Fax:702-469-3590
Practice Address - Street 1:4760 N BUTLER AVE STE A
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-0816
Practice Address - Country:US
Practice Address - Phone:702-469-3590
Practice Address - Fax:702-469-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD33991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty