# DAVID G WILSON DMD LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** DAVID G WILSON DMD LLC
- **Other names:** Wilson Orthodontics
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1154773489
- **Legal business name:** DAVID G WILSON DMD LLC
- **Authorized official:** DR. DAVID G WILSON DMD (OWNER/ORTHODONTIST)
- **Authorized official phone:** (570) 850-8119

## Contact information

- **Practice address:** 1372 N SUSQUEHANNA TRL STE 140, SELINSGROVE, PA 17870-8973
- **Practice address phone:** (570) 743-8119
- **Practice address fax:** (570) 743-2009
- **Mailing address:** 1372 N SUSQUEHANNA TRL STE 140, SELINSGROVE, PA 17870-8973
- **Mailing address phone:** (570) 743-8119
- **Mailing address fax:** (570) 743-2009

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | DS019605L | PA | Yes |
| 332BC3200X | Customized Equipment (DME) | — | NULL | — |

## Other

- **Enumeration date:** 07/11/2016
- **Last updated:** 10/20/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 7556450001 | MEDICARE DME PTAN NUMBER | PA |