Healthcare Provider Details

I. General information

NPI: 1902827199
Provider Name (Legal Business Name): KAROLE H WILSON D.M.D., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9370 SW GREENBURG RD STE T
PORTLAND OR
97223-5408
US

IV. Provider business mailing address

9370 SW GREENBURG RD STE T
PORTLAND OR
97223-5408
US

V. Phone/Fax

Practice location:
  • Phone: 503-245-1915
  • Fax: 503-245-5956
Mailing address:
  • Phone: 503-245-1915
  • Fax: 503-245-5956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7753
License Number StateOR

VIII. Authorized Official

Name: DR. KAROLE H WILSON
Title or Position: DOCTOR
Credential: D.M.D. PC
Phone: 503-245-1915