Healthcare Provider Details

I. General information

NPI: 1598774465
Provider Name (Legal Business Name): JACK W. WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 LUZERNE ST
MOUNT IDA AR
71957-9449
US

IV. Provider business mailing address

1201 MENA ST
MENA AR
71953-4280
US

V. Phone/Fax

Practice location:
  • Phone: 870-867-4244
  • Fax: 870-867-4254
Mailing address:
  • Phone: 479-394-2332
  • Fax: 479-437-3708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5303
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: