MEDICARE: DANIEL E. WILSON, DMD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D7955	OR
2	1223G0001X	General Practice Dentistry	DE00009284	WA

General Provider Information

NPI Number	:	1669973160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANIEL E. WILSON, DMD PC

Provider Business Mailing Address
First Line	:	16703 SE MCGILLIVRAY BLVD STE 100
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-3418
Country	:	US
Telephone Number	:	360-892-2994
Fax Number	:	360-892-3929

Provider Business Practice Location Address
First Line	:	16703 SE MCGILLIVRAY BLVD STE 100
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-3418
Country	:	US
Telephone Number	:	360-892-2994
Fax Number	:	360-892-3929

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. DANIEL EDWIN WILSON
Credential	:	DMD
Telephone Number	:	360-314-8723

Provider Enumeration Date	:	02/21/2018
Last Update Date	:	02/21/2018

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