Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 5037 | TN |
N | 1223P0700X | Prosthodontist | 5037 | TN |
NPI | 1144292814 |
---|---|
Provider Name | Dalton Phillip Wilson |
First Address | Offutt A F B, NE 68113-1043 |
Second Address | Offutt A F B, NE 68113-1043 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2006 |
Last Update Date | 08/07/2007 |