Provider Demographics
NPI:1730159880
Name:WARD, WILSON E (DDS)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:E
Last Name:WARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 GREAT TEAYS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9552
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-757-3252
Practice Address - Street 1:116 HILLS PLZ
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2438
Practice Address - Country:US
Practice Address - Phone:304-414-4493
Practice Address - Fax:304-720-4813
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1787122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001470512OtherMS BCBS
WV0136119000Medicaid
WV5462128OtherAETNA