Provider Demographics
NPI:1245314277
Name:WILSON, JANICE MARIE (DMD RN)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11568
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-4268
Mailing Address - Country:US
Mailing Address - Phone:913-428-1670
Mailing Address - Fax:
Practice Address - Street 1:360 NEW ALBANY PLZ
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4654
Practice Address - Country:US
Practice Address - Phone:812-618-9346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY7035122300000X
IN12013054A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist