Provider Demographics
NPI:1497949929
Name:WILSON, JACK L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1721 S CLEVELAND AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-5501
Mailing Address - Country:US
Mailing Address - Phone:605-978-9000
Mailing Address - Fax:605-978-9009
Practice Address - Street 1:1721 S CLEVELAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-5501
Practice Address - Country:US
Practice Address - Phone:605-978-9000
Practice Address - Fax:605-978-9009
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM4701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics