Provider Demographics
NPI:1770713620
Name:WILSON, ELIZABETH M (DMD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:HOLLIDAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:530 N TELSHOR BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8243
Mailing Address - Country:US
Mailing Address - Phone:575-532-5861
Mailing Address - Fax:
Practice Address - Street 1:530 N TELSHOR BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8243
Practice Address - Country:US
Practice Address - Phone:575-532-5861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD 3170122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist