Healthcare Provider Details

I. General information

NPI: 1417246562
Provider Name (Legal Business Name): DR. JOSEPH A. WILSON DMD, MSD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 N BUTLER AVE STE A
FARMINGTON NM
87401-0816
US

IV. Provider business mailing address

4760 N BUTLER AVESUITE A
FARMINGTON NM
87401
US

V. Phone/Fax

Practice location:
  • Phone: 702-469-3590
  • Fax: 702-469-3590
Mailing address:
  • Phone: 702-469-3590
  • Fax: 702-469-3590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD3399
License Number StateNM

VIII. Authorized Official

Name: DR. JOSEPH A WILSON
Title or Position: OWNER
Credential: DMD MSD LLC
Phone: 702-469-3590