Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | M367 | SD |
NPI | 1437125721 |
---|---|
Provider Name | Dr. Roger Cave Wilson |
First Address | Rapid City, SD 57701-7365 |
Second Address | Rapid City, SD 57701-7365 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2006 |
Last Update Date | 27/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8000050 | (05) | SD |
U35043 | (02) | SD |