Provider Demographics
NPI:1609076025
Name:WILSON, PHILIP MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:MICHAEL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 COONEY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-6677
Mailing Address - Country:US
Mailing Address - Phone:936-615-1792
Mailing Address - Fax:
Practice Address - Street 1:690 SW HIGGINS AVE STE H
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1433
Practice Address - Country:US
Practice Address - Phone:406-543-3159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT273411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice