Healthcare Provider Details

I. General information

NPI: 1669211538
Provider Name (Legal Business Name): KRISTINA N WILSON DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/21/2024
Certification Date: 02/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18275 N 59TH AVE STE 150
GLENDALE AZ
85308-1253
US

IV. Provider business mailing address

5527 W ANDREA DR
PHOENIX AZ
85083-6361
US

V. Phone/Fax

Practice location:
  • Phone: 602-942-0623
  • Fax:
Mailing address:
  • Phone: 623-293-6765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTINA N WILSON
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 623-293-6765