Provider Demographics
NPI:1548388465
Name:WILSON, REBECCA LEIGH (RDH)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22187 STATE HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:DEERWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56444-6279
Mailing Address - Country:US
Mailing Address - Phone:218-851-1812
Mailing Address - Fax:612-235-3391
Practice Address - Street 1:22187 STATE HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:DEERWOOD
Practice Address - State:MN
Practice Address - Zip Code:56444-6279
Practice Address - Country:US
Practice Address - Phone:218-851-1812
Practice Address - Fax:612-235-3391
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH6525124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist