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General NPI Number Information
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NPI Number | 1093111270
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Entity Type | Organization
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Legal Business Name | DENTAL STUDIO ON 30TH STREET PC
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Dates
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Enumeration Date | 11/14/2014
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Last Update Date | 11/14/2014
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Provider Practice Location Address
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Address Line | 2401 E 30TH ST
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City | FARMINGTON
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State | NM
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Zip | 87401-8939
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Country | US
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Telephone | 505-325-8858
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Fax |
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Provider Business Mailing Address
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Address Line | 2401 E 30TH ST
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City | FARMINGTON
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State | NM
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Zip | 87401-8939
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Country | US
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Telephone | 505-325-8858
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JOSEPH WILSON
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Credential | DMD, MSD, LLC
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Telephone | 505-360-9592
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DD3399
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License Number State | NM
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