Provider Demographics
NPI:1760645980
Name:WILSON, MARLA K (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARLA
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 S EAST ST
Mailing Address - Street 2:STE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2214
Mailing Address - Country:US
Mailing Address - Phone:317-787-6625
Mailing Address - Fax:317-787-4945
Practice Address - Street 1:6920 S EAST ST
Practice Address - Street 2:STE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2214
Practice Address - Country:US
Practice Address - Phone:317-787-6625
Practice Address - Fax:317-787-4945
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120096901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice