Provider Demographics
NPI:1598869745
Name:WILSON, MARK D (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
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 1:7471 SW BARBUR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2809
Mailing Address - Country:US
Mailing Address - Phone:503-246-8447
Mailing Address - Fax:503-245-6631
Practice Address - Street 1:7471 SW BARBUR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2809
Practice Address - Country:US
Practice Address - Phone:503-246-8447
Practice Address - Fax:503-245-6631
Is Sole Proprietor?:No
Enumeration Date:2006-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice