Healthcare Provider Details

I. General information

NPI: 1437125721
Provider Name (Legal Business Name): ROGER CAVE WILSON DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 5TH ST
RAPID CITY SD
57701-7365
US

IV. Provider business mailing address

3415 5TH ST
RAPID CITY SD
57701-7365
US

V. Phone/Fax

Practice location:
  • Phone: 605-348-6818
  • Fax: 605-348-4690
Mailing address:
  • Phone: 605-348-6818
  • Fax: 605-348-4690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberM367
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: