Provider Demographics
NPI:1780816272
Name:WILSON, LAURA BRUYA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:BRUYA
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 1:956 E 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-6202
Mailing Address - Country:US
Mailing Address - Phone:206-999-8724
Mailing Address - Fax:
Practice Address - Street 1:12706 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1053
Practice Address - Country:US
Practice Address - Phone:509-928-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60168082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist