Provider Demographics
NPI:1598774465
Name:WILSON, JACK W (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
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 1:1201 MENA ST
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-4280
Mailing Address - Country:US
Mailing Address - Phone:479-394-2332
Mailing Address - Fax:479-437-3708
Practice Address - Street 1:534 LUZERNE ST
Practice Address - Street 2:
Practice Address - City:MOUNT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957-9449
Practice Address - Country:US
Practice Address - Phone:870-867-4244
Practice Address - Fax:870-867-4254
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK450463188002OtherBLUE CROSS BLUE SHIELD