Provider Demographics
NPI:1851788988
Name:WILSON, RACHAEL ANNE
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:
Other - Last Name:RATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3800 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-2731
Mailing Address - Country:US
Mailing Address - Phone:406-672-0187
Mailing Address - Fax:
Practice Address - Street 1:4200 WEST OLD SHAKOPEE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437
Practice Address - Country:US
Practice Address - Phone:952-831-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13547122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist