Healthcare Provider Details

I. General information

NPI: 1477897155
Provider Name (Legal Business Name): THOMAS K WILSON DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S SANTA FE AVE 240
SALINA KS
67401-4190
US

IV. Provider business mailing address

520 S SANTA FE AVE 240
SALINA KS
67401-4190
US

V. Phone/Fax

Practice location:
  • Phone: 785-827-9325
  • Fax: 785-827-6252
Mailing address:
  • Phone: 785-827-9325
  • Fax: 785-827-6252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5719
License Number StateKS

VIII. Authorized Official

Name: THOMAS K WILSON
Title or Position: PROPRIETOR
Credential: DMD
Phone: 785-827-9325