1346351525 NPI number — MR. DAN R WILSON DDS

Table of content: MR. DAN R WILSON DDS (NPI 1346351525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346351525 NPI number — MR. DAN R WILSON DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
DAN
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1346351525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
813 1/2 COLUMBIA STREET
Provider Second Line Business Practice Location Address:
813 1/2 COLUMBIA #99
Provider Business Practice Location Address City Name:
POMEROY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-834-3495
Provider Business Practice Location Address Fax Number:
509-843-3496
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5974 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: D1862 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2074241 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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