Healthcare Provider Details

I. General information

NPI: 1992708952
Provider Name (Legal Business Name): DAVID G WILSON D.M.D., LLC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1372 N SUSQUEHANNA TRL SUITE 140
SELINSGROVE PA
17870-8971
US

IV. Provider business mailing address

1372 N SUSQUEHANNA TRL SUITE 140
SELINSGROVE PA
17870-8971
US

V. Phone/Fax

Practice location:
  • Phone: 570-743-8119
  • Fax: 570-743-2009
Mailing address:
  • Phone: 570-743-8119
  • Fax: 570-743-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS019605-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: