Healthcare Provider Details

I. General information

NPI: 1265220834
Provider Name (Legal Business Name): KIRK WILSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2036 S MILLER LN STE B
CATOOSA OK
74015-1539
US

IV. Provider business mailing address

13305 S 93RD EAST AVE
BIXBY OK
74008-3542
US

V. Phone/Fax

Practice location:
  • Phone: 918-266-6470
  • Fax:
Mailing address:
  • Phone: 818-770-8518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8068
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: