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General NPI Number Information
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NPI Number | 1780760058
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Entity Type | Organization
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Legal Business Name | CLARENCE J WILSON JR DDS INC
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Dates
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Enumeration Date | 10/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 109 E 5TH ST
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City | CORUTHERSVILLE
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State | MO
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Zip | 63830
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Country | US
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Telephone | 573-333-1550
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Fax | 573-333-0055
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Provider Business Mailing Address
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Address Line | PO BOX 937 109 E 5TH ST
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City | CARUTHERSVILLE
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State | MO
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Zip | 63830
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Country | US
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Telephone | 573-333-1550
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Fax | 573-333-0055
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | DR. CLARENCE JAMES WILSON JR.
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Credential | DDS
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Telephone | 573-333-1550
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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 | 13167
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License Number State | MO
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