Provider Demographics
NPI:1669973160
Name:DANIEL E. WILSON, DMD PC
Entity type:Organization
Organization Name:DANIEL E. WILSON, DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-314-8723
Mailing Address - Street 1:16703 SE MCGILLIVRAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-3418
Mailing Address - Country:US
Mailing Address - Phone:360-892-2994
Mailing Address - Fax:360-892-3929
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:360-892-3929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD79551223G0001X
WADE000092841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty