Healthcare Provider Details

I. General information

NPI: 1750502159
Provider Name (Legal Business Name): KATHERINE DUNN WILSON D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 STATE RD STE 102
KITTERY ME
03904-1562
US

IV. Provider business mailing address

74 STATE RD STE 102
KITTERY ME
03904-1562
US

V. Phone/Fax

Practice location:
  • Phone: 303-913-6462
  • Fax:
Mailing address:
  • Phone: 303-913-6462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3671
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: