Provider Demographics
NPI:1578633046
Name:WILSON, MARK K (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:K
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72370
Mailing Address - Country:US
Mailing Address - Phone:870-563-6900
Mailing Address - Fax:870-563-8298
Practice Address - Street 1:107 N MAPLE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370
Practice Address - Country:US
Practice Address - Phone:870-563-6900
Practice Address - Fax:870-563-8298
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist