Provider Demographics
NPI:1932494127
Name:WILSON, JOHN C (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4331 HUCKLEBERRY LN S
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-1504
Mailing Address - Country:US
Mailing Address - Phone:801-921-3603
Mailing Address - Fax:
Practice Address - Street 1:2675 CENTRAL AVE STE L8
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6686
Practice Address - Country:US
Practice Address - Phone:406-294-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7999864-8903122300000X
MTDEN-DEN-LIC-115581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist