Provider Demographics
NPI:1700984689
Name:DR. K. P. WILSON, PLLC
Entity type:Organization
Organization Name:DR. K. P. WILSON, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:MARTINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-624-5250
Mailing Address - Street 1:516 COST AVE
Mailing Address - Street 2:
Mailing Address - City:STONEWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4811
Mailing Address - Country:US
Mailing Address - Phone:304-624-5250
Mailing Address - Fax:304-624-5251
Practice Address - Street 1:930 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1673
Practice Address - Country:US
Practice Address - Phone:304-842-7568
Practice Address - Fax:304-842-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV30701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001853OtherWV DENTAL MEDICAL CARD