Healthcare Provider Details

I. General information

NPI: 1457976193
Provider Name (Legal Business Name): CLINTON ARLIN WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 W 41ST ST
SIOUX FALLS SD
57106-1217
US

IV. Provider business mailing address

6301 W 41ST ST
SIOUX FALLS SD
57106-1217
US

V. Phone/Fax

Practice location:
  • Phone: 605-305-4141
  • Fax:
Mailing address:
  • Phone: 605-305-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD1262
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: