Provider Demographics
NPI:1912924424
Name:WILSON, MARK EDWARD (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8052
Mailing Address - Country:US
Mailing Address - Phone:501-771-2990
Mailing Address - Fax:
Practice Address - Street 1:4605 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116
Practice Address - Country:US
Practice Address - Phone:501-771-2990
Practice Address - Fax:501-753-0408
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR28171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58323OtherBLUECROSS BLUESHIELD
AR115618608Medicaid