Provider Demographics
NPI:1134524465
Name:WILSON, DESY P (DDS, MS)
Entity type:Individual
Prefix:
First Name:DESY
Middle Name:P
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 NE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1634
Mailing Address - Country:US
Mailing Address - Phone:541-474-0860
Mailing Address - Fax:541-476-1038
Practice Address - Street 1:859 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1634
Practice Address - Country:US
Practice Address - Phone:541-474-0860
Practice Address - Fax:541-476-1038
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD98231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics