Provider Demographics
NPI:1023131349
Name:WILSON, DWIGHT CLARENCE (DMD)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:CLARENCE
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 1:1740 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-8966
Mailing Address - Country:US
Mailing Address - Phone:270-274-5076
Mailing Address - Fax:270-298-7286
Practice Address - Street 1:1117 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:KY
Practice Address - Zip Code:42347-1835
Practice Address - Country:US
Practice Address - Phone:270-298-7923
Practice Address - Fax:270-298-7286
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5784122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist