Provider Demographics
NPI:1821686684
Name:DR. BRUCE T. WILSON D.D.S., PA
Entity Type:Organization
Organization Name:DR. BRUCE T. WILSON D.D.S., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-561-4400
Mailing Address - Street 1:PO BOX 1345
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-1345
Mailing Address - Country:US
Mailing Address - Phone:870-561-4400
Mailing Address - Fax:
Practice Address - Street 1:3455 W STATE HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442-8005
Practice Address - Country:US
Practice Address - Phone:870-561-4400
Practice Address - Fax:870-561-4037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180606608Medicaid