Provider Demographics
NPI:1144292814
Name:WILSON, DALTON PHILLIP (DENTIST)
Entity type:Individual
Prefix:
First Name:DALTON
Middle Name:PHILLIP
Last Name:WILSON
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CAPEHART RD
Mailing Address - Street 2:55 MEDICAL GROUP
Mailing Address - City:OFFUTT A F B
Mailing Address - State:NE
Mailing Address - Zip Code:68113-1043
Mailing Address - Country:US
Mailing Address - Phone:402-232-9208
Mailing Address - Fax:402-294-9250
Practice Address - Street 1:2501 CAPEHART RD
Practice Address - Street 2:55 MEDICAL GROUP
Practice Address - City:OFFUTT A F B
Practice Address - State:NE
Practice Address - Zip Code:68113-1043
Practice Address - Country:US
Practice Address - Phone:402-232-9208
Practice Address - Fax:402-294-9250
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN50371223P0700X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0700XDental ProvidersDentistProsthodontics
Not Answered122300000XDental ProvidersDentist