Healthcare Provider Details

I. General information

NPI: 1912924424
Provider Name (Legal Business Name): MARK EDWARD WILSON DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 FAIRWAY AVE
NORTH LITTLE ROCK AR
72116
US

IV. Provider business mailing address

4605 FAIRWAY AVE
NORTH LITTLE ROCK AR
72116-8052
US

V. Phone/Fax

Practice location:
  • Phone: 501-771-2990
  • Fax: 501-753-0408
Mailing address:
  • Phone: 501-771-2990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2817
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: