Individual
RANDAL TODD WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
1309 BENNETT AVE, BURLEY, ID 83318-2676
(208) 677-5198
Mailing address
794 EASTLAND DR, TWIN FALLS, ID 83301-6856
(208) 734-3312
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D-4526
ID
Other
Enumeration date
08/21/2013
Last updated
03/17/2021
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