Provider Demographics
NPI:1750576633
Name:DR J BRAD WILSON & DR KIM BADELL WILSON INC
Entity type:Organization
Organization Name:DR J BRAD WILSON & DR KIM BADELL WILSON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:BRAD
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-482-1855
Mailing Address - Street 1:288 NORTHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1212
Mailing Address - Country:US
Mailing Address - Phone:812-482-1855
Mailing Address - Fax:812-634-6833
Practice Address - Street 1:288 NORTHWOOD AVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1212
Practice Address - Country:US
Practice Address - Phone:812-482-1855
Practice Address - Fax:812-634-6833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN82441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty