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General NPI Number Information
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NPI Number | 1891316535
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Entity Type | Organization
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Legal Business Name | RANDALL E WILSON DDS
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Dates
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Enumeration Date | 05/05/2020
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Last Update Date | 07/23/2025
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Provider Practice Location Address
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Address Line | 4121 OLD COLLINSVILLE RD
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City | SWANSEA
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State | IL
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Zip | 62226-2511
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Country | US
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Telephone | 618-236-0501
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Fax |
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Provider Business Mailing Address
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Address Line | 4121 OLD COLLINSVILLE RD
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City | SWANSEA
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State | IL
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Zip | 62226-2511
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Country | US
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Telephone | 618-236-0501
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. RANDALL E WILSON
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Credential | DDS
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Telephone | 618-236-0501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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