Healthcare Provider Details

I. General information

NPI: 1447471370
Provider Name (Legal Business Name): CHERYL WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10827 S 51ST ST STE 201
PHOENIX AZ
85044-1742
US

IV. Provider business mailing address

10827 S 51ST ST STE 201
PHOENIX AZ
85044-1742
US

V. Phone/Fax

Practice location:
  • Phone: 480-893-0888
  • Fax:
Mailing address:
  • Phone: 480-893-0888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1817
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: