Provider Demographics
NPI:1821215781
Name:WILSON, KIM BADELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:BADELL
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 1:288 NORTHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1212
Mailing Address - Country:US
Mailing Address - Phone:812-482-1855
Mailing Address - Fax:812-634-6833
Practice Address - Street 1:288 NORTHWOOD AVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1212
Practice Address - Country:US
Practice Address - Phone:812-482-1855
Practice Address - Fax:812-634-6833
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN82451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice