Provider Demographics
NPI:1740486604
Name:DAVID L. WILSON, DMD, PC
Entity type:Organization
Organization Name:DAVID L. WILSON, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-639-4330
Mailing Address - Street 1:14300 SW PACIFIC HWY
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3790
Mailing Address - Country:US
Mailing Address - Phone:503-639-4330
Mailing Address - Fax:503-639-5400
Practice Address - Street 1:14300 SW PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-3790
Practice Address - Country:US
Practice Address - Phone:503-639-4330
Practice Address - Fax:503-639-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty