Provider Demographics
NPI:1619174661
Name:WILSON, OWEN DALE (DMD)
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:DALE
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 1:1713 ELIZABETHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-8128
Mailing Address - Country:US
Mailing Address - Phone:270-259-3003
Mailing Address - Fax:270-259-5408
Practice Address - Street 1:1713 ELIZABETHTOWN RD
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-8128
Practice Address - Country:US
Practice Address - Phone:270-259-3003
Practice Address - Fax:270-259-5408
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60056140Medicaid