Provider Demographics
NPI:1669461117
Name:WILSON, TROY L (DDS, PC)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS, PC
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 981
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-0981
Mailing Address - Country:US
Mailing Address - Phone:505-445-8370
Mailing Address - Fax:505-445-3369
Practice Address - Street 1:112 GRANT AVE
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2526
Practice Address - Country:US
Practice Address - Phone:505-445-8370
Practice Address - Fax:505-445-3369
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM16401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM88989Medicaid