Healthcare Provider Details

I. General information

NPI: 1770713620
Provider Name (Legal Business Name): ELIZABETH M WILSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH HOLLIDAY DMD

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N TELSHOR BLVD SUITE A
LAS CRUCES NM
88011-8243
US

IV. Provider business mailing address

530 N TELSHOR BLVD SUITE A
LAS CRUCES NM
88011-8243
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-5861
  • Fax:
Mailing address:
  • Phone: 575-532-5861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD 3170
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: