Provider Demographics
NPI:1053525253
Name:BRIAN J. WILSON DDS, PC
Entity type:Organization
Organization Name:BRIAN J. WILSON DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-938-7750
Mailing Address - Street 1:17250 N 43RD AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4035
Mailing Address - Country:US
Mailing Address - Phone:602-938-7750
Mailing Address - Fax:602-938-0765
Practice Address - Street 1:17250 N 43RD AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4035
Practice Address - Country:US
Practice Address - Phone:602-938-7750
Practice Address - Fax:602-938-0765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ18261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty