Provider Demographics
NPI:1023347945
Name:WILSON, JOHN GORDON (LD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GORDON
Last Name:WILSON
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 NICOLE WAY
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-6183
Mailing Address - Country:US
Mailing Address - Phone:541-523-8529
Mailing Address - Fax:
Practice Address - Street 1:715 NICOLE WAY
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-6183
Practice Address - Country:US
Practice Address - Phone:541-523-8529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-24
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDTDO10126518122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist