MEDICARE: MR. DAN R WILSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5974	WA
2	1223G0001X	General Practice Dentistry	D1862	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346351525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAN R WILSON DDS

Provider Business Mailing Address
First Line	:	PO BOX 99
Second Line	:
City	:	POMEROY
State	:	WA
Zip	:	99347-0099
Country	:	US
Telephone Number	:	509-843-3495
Fax Number	:	509-843-3496

Provider Business Practice Location Address
First Line	:	813 1/2 COLUMBIA STREET
Second Line	:	813 1/2 COLUMBIA #99
City	:	POMEROY
State	:	WA
Zip	:	99347
Country	:	US
Telephone Number	:	509-834-3495
Fax Number	:	509-843-3496

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	03/06/2019

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Directions to “ MR. DAN R WILSON DDS” Practice Location

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