Provider Demographics
NPI:1922530823
Name:WILSON DENTISTRY LLC
Entity Type:Organization
Organization Name:WILSON DENTISTRY LLC
Other - Org Name:IMAGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-551-8040
Mailing Address - Street 1:11711 N PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-6959
Mailing Address - Country:US
Mailing Address - Phone:317-816-0841
Mailing Address - Fax:
Practice Address - Street 1:11711 N PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-6959
Practice Address - Country:US
Practice Address - Phone:317-816-0841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012331A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty