Provider Demographics
NPI:1821536269
Name:WILSON, HEIDI (DENIAL HYGINIST)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DENIAL HYGINIST
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 427
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-0427
Mailing Address - Country:US
Mailing Address - Phone:989-354-2197
Mailing Address - Fax:989-354-1952
Practice Address - Street 1:21258 M 68 HWY
Practice Address - Street 2:
Practice Address - City:ONAWAY
Practice Address - State:MI
Practice Address - Zip Code:49765-9692
Practice Address - Country:US
Practice Address - Phone:989-733-2082
Practice Address - Fax:989-733-8487
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902010470124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist