Provider Demographics
NPI:1598007379
Name:WILSON DENTAL CARE GR PC
Entity Type:Organization
Organization Name:WILSON DENTAL CARE GR PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHI
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-454-1482
Mailing Address - Street 1:1625 DIAMOND AVE NE
Mailing Address - Street 2:STE 1
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4887
Mailing Address - Country:US
Mailing Address - Phone:616-454-1482
Mailing Address - Fax:616-454-4422
Practice Address - Street 1:1625 DIAMOND AVE NE
Practice Address - Street 2:STE 1
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4887
Practice Address - Country:US
Practice Address - Phone:616-454-1482
Practice Address - Fax:616-454-4422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI179481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty