Healthcare Provider Details

I. General information

NPI: 1013192913
Provider Name (Legal Business Name): SPENCER G WILSON DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 S HIGLEY RD STE 106
GILBERT AZ
85296-4799
US

IV. Provider business mailing address

1355 S HIGLEY RD STE 106
GILBERT AZ
85296-4799
US

V. Phone/Fax

Practice location:
  • Phone: 480-279-5949
  • Fax: 480-279-0784
Mailing address:
  • Phone: 480-279-5949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD0020739
License Number StateAZ

VIII. Authorized Official

Name: DR. SPENCER G WILSON
Title or Position: PRESIDENT
Credential: D.D.S
Phone: 480-279-5949