Provider Demographics
NPI:1205048089
Name:WILSON, JOHN RUSSELL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSSELL
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 1:325 COLLEGE LN
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4591
Mailing Address - Country:US
Mailing Address - Phone:307-382-5428
Mailing Address - Fax:
Practice Address - Street 1:2441 FOOTHILL BLVD
Practice Address - Street 2:SUITE 1171B
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5659
Practice Address - Country:US
Practice Address - Phone:307-382-5902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice