Provider Demographics
NPI:1053795294
Name:DR WILSON AND DR KRAUSE, LLC
Entity type:Organization
Organization Name:DR WILSON AND DR KRAUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-856-2177
Mailing Address - Street 1:8401 HOWLAND SPRINGS RD SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-3120
Mailing Address - Country:US
Mailing Address - Phone:330-856-2177
Mailing Address - Fax:
Practice Address - Street 1:8401 HOWLAND SPRINGS RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3120
Practice Address - Country:US
Practice Address - Phone:330-856-2177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19817122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty