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General NPI Number Information
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NPI Number | 1417246562
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Entity Type | Organization
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Legal Business Name | DR. JOSEPH A. WILSON DMD, MSD, LLC
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Dates
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Enumeration Date | 03/29/2011
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Last Update Date | 03/29/2011
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Provider Practice Location Address
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Address Line | 4760 N BUTLER AVE STE A
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City | FARMINGTON
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State | NM
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Zip | 87401-0816
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Country | US
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Telephone | 702-469-3590
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Fax | 702-469-3590
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Provider Business Mailing Address
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Address Line | 4760 N BUTLER AVESUITE A
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City | FARMINGTON
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State | NM
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Zip | 87401
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Country | US
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Telephone | 702-469-3590
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Fax | 702-469-3590
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOSEPH A WILSON
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Credential | DMD MSD LLC
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Telephone | 702-469-3590
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DD3399
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License Number State | NM
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