Provider Demographics
NPI:1790212173
Name:WILSON, DALLIN (OD)
Entity Type:Individual
Prefix:
First Name:DALLIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 S 100 E
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3925
Mailing Address - Country:US
Mailing Address - Phone:435-773-5938
Mailing Address - Fax:
Practice Address - Street 1:2276 E RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2636
Practice Address - Country:US
Practice Address - Phone:435-773-5938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
UT10408308-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program