Provider Demographics
NPI:1912190539
Name:DRS E HAWKINS M A WILSON & J D LINDSAY III PTRS
Entity Type:Organization
Organization Name:DRS E HAWKINS M A WILSON & J D LINDSAY III PTRS
Other - Org Name:MORGANTOWN DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-292-7307
Mailing Address - Street 1:142 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-5413
Mailing Address - Country:US
Mailing Address - Phone:304-292-7307
Mailing Address - Fax:304-292-1154
Practice Address - Street 1:142 HIGH ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-5413
Practice Address - Country:US
Practice Address - Phone:304-292-7307
Practice Address - Fax:304-292-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2381 MICHAEL A WILSO122300000X, 122300000X, 122300000X
WV3665 JOSHUA M DOLIN122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7277350001Medicare UPIN