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General NPI Number Information
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NPI Number | 1598774465
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Entity Type | Individual
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Provider Name | JACK W. WILSON DDS
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Gender | Male
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Dates
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Enumeration Date | 08/07/2006
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Last Update Date | 04/14/2008
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Provider Practice Location Address
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Address Line | 534 LUZERNE ST
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City | MOUNT IDA
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State | AR
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Zip | 71957-9449
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Country | US
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Telephone | 870-867-4244
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Fax | 870-867-4254
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Provider Business Mailing Address
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Address Line | 1201 MENA ST
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City | MENA
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State | AR
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Zip | 71953-4280
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Country | US
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Telephone | 479-394-2332
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Fax | 479-437-3708
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 5303
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License Number State | OK
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