Provider Demographics
NPI:1780334664
Name:WILSON, SHANE A
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WATSON CIR
Mailing Address - Street 2:
Mailing Address - City:GRAVOIS MILLS
Mailing Address - State:MO
Mailing Address - Zip Code:65037-4625
Mailing Address - Country:US
Mailing Address - Phone:763-528-5539
Mailing Address - Fax:
Practice Address - Street 1:110 WATSON CIR
Practice Address - Street 2:
Practice Address - City:GRAVOIS MILLS
Practice Address - State:MO
Practice Address - Zip Code:65037-4625
Practice Address - Country:US
Practice Address - Phone:763-528-5539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022019208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist