Provider Demographics
NPI:1134431729
Name:WILSON, ANDREA LYNN (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4820
Mailing Address - Country:US
Mailing Address - Phone:701-271-3344
Mailing Address - Fax:
Practice Address - Street 1:306 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4820
Practice Address - Country:US
Practice Address - Phone:701-271-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2076122300000X
MND12854122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist