Provider Demographics
NPI:1780760058
Name:CLARENCE J WILSON JR DDS INC
Entity type:Organization
Organization Name:CLARENCE J WILSON JR DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-333-1550
Mailing Address - Street 1:PO BOX 937
Mailing Address - Street 2:109 E 5TH ST
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830
Mailing Address - Country:US
Mailing Address - Phone:573-333-1550
Mailing Address - Fax:573-333-0055
Practice Address - Street 1:109 E 5TH ST
Practice Address - Street 2:
Practice Address - City:CORUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830
Practice Address - Country:US
Practice Address - Phone:573-333-1550
Practice Address - Fax:573-333-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO131671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty