1700984689 NPI number — DR. K. P. WILSON, PLLC

Table of content: (NPI 1700984689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700984689 NPI number — DR. K. P. WILSON, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. K. P. WILSON, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WILSON MARTINO DENTAL OF BRIDGEPORT
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700984689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
516 COST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONEWOOD
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26301-4811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-624-5250
Provider Business Mailing Address Fax Number:
304-624-5251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-842-7568
Provider Business Practice Location Address Fax Number:
304-842-2202
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINO
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
V
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
304-624-5250

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3070 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810001853 . This is a "WV DENTAL MEDICAL CARD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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