Provider Demographics
NPI:1992820328
Name:WILSON, DANIEL EDWIN (DMD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:EDWIN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:DAN
Other - Middle Name:E
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:801 NW 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-4309
Mailing Address - Country:US
Mailing Address - Phone:360-314-8723
Mailing Address - Fax:
Practice Address - Street 1:16703 SE MCGILLIVRAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3418
Practice Address - Country:US
Practice Address - Phone:360-892-2994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000092841223G0001X
ORD79551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice