=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265723357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILA PATRICIA WILSON D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2011
-----------------------------------------------------
Last Update Date | 04/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8889 TRILLIUM DR
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-9499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-277-6161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8889 TRILLIUM DR
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-9499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-277-6161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 60306
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------