MEDICARE: DR. DANIEL EDWIN WILSON DMD

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	DE00009284	WA
2	1223G0001X	General Practice Dentistry	D7955	OR

General Provider Information

NPI Number	:	1992820328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL EDWIN WILSON DMD

Provider Business Mailing Address
First Line	:	801 NW 44TH AVE
Second Line	:
City	:	CAMAS
State	:	WA
Zip	:	98607-4309
Country	:	US
Telephone Number	:	360-314-8723
Fax Number	:

Provider Business Practice Location Address
First Line	:	16703 SE MCGILLIVRAY BLVD STE 100
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-3418
Country	:	US
Telephone Number	:	360-892-2994
Fax Number	:

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	07/21/2022

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