MEDICARE: DR. CLINTON ARLIN 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	122300000X	Dentist	D1262	SD

General Provider Information

NPI Number	:	1457976193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLINTON ARLIN WILSON DDS

Provider Business Mailing Address
First Line	:	6301 W 41ST ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-1217
Country	:	US
Telephone Number	:	605-305-4141
Fax Number	:

Provider Business Practice Location Address
First Line	:	6301 W 41ST ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-1217
Country	:	US
Telephone Number	:	605-305-4141
Fax Number	:

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

Provider Enumeration Date	:	06/09/2020
Last Update Date	:	06/09/2020

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