Provider Demographics
NPI:1548561038
Name:WILSON, JOSEPH A (DMD, MSD, LLC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD, MSD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 N BUTLER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-0816
Mailing Address - Country:US
Mailing Address - Phone:702-469-3590
Mailing Address - Fax:702-469-3590
Practice Address - Street 1:4760 N BUTLER AVE
Practice Address - Street 2:SUITE A
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
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3399122300000X, 1223X0400X
UT49293029922122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist