Healthcare Provider Details

I. General information

NPI: 1104042761
Provider Name (Legal Business Name): RICHARD LYMAN WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 WEEMINUCHE AVE
IGNACIO CO
81137
US

IV. Provider business mailing address

PO BOX 737 SUHC
IGNACIO CO
81137-0737
US

V. Phone/Fax

Practice location:
  • Phone: 970-563-4581
  • Fax: 970-563-4581
Mailing address:
  • Phone: 970-563-4581
  • Fax: 970-563-4581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberCO7355
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: