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General NPI Number Information
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NPI Number | 1770787657
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Entity Type | Organization
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Legal Business Name | MARLA WILSON DDS PC
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Dates
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Enumeration Date | 06/13/2007
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Last Update Date | 12/06/2016
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Provider Practice Location Address
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Address Line | 6920 S EAST ST SUITE A
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City | INDIANAPOLIS
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State | IN
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Zip | 46227-2215
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Country | US
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Telephone | 317-787-6625
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Fax | 317-787-4945
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Provider Business Mailing Address
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Address Line | 6920 S EAST ST SUITE A
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City | INDIANAPOLIS
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State | IN
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Zip | 46227-2215
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Country | US
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Telephone | 317-787-6625
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Fax | 317-787-4945
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Authorized Official
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Title or Position | DENTIST
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Name | MARLA KAY WILSON
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Credential | DDS
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Telephone | 317-787-6625
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12009690
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License Number State | IN
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