Provider Demographics
NPI:1952455347
Name:WILSON, JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 KITTY DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433
Mailing Address - Country:US
Mailing Address - Phone:303-838-7904
Mailing Address - Fax:303-838-0318
Practice Address - Street 1:10801 KITTY DRIVE
Practice Address - Street 2:
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433
Practice Address - Country:US
Practice Address - Phone:303-838-7904
Practice Address - Fax:303-838-0318
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO686122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist