Provider Demographics
NPI:1568089076
Name:WILSON, JENS (DMD)
Entity Type:Individual
Prefix:
First Name:JENS
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
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 STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-0816
Mailing Address - Country:US
Mailing Address - Phone:435-459-4457
Mailing Address - Fax:
Practice Address - Street 1:2650 E PINON FRONTAGE RD BLDG 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5084
Practice Address - Country:US
Practice Address - Phone:505-599-9359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL-541-201223P0221X
NMDD55971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry