Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 08321 | IA |
NPI | 1013026657 |
---|---|
Provider Name | Bryan M Wilson |
First Address | Apo, AP 96278-2060 |
Second Address | Apo, AP 96278-2060 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/08/2006 |
Last Update Date | 08/07/2007 |