Individual
JACK W. WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
534 LUZERNE ST, MOUNT IDA, AR 71957-9449
(870) 867-4244
(870) 867-4254
Mailing address
1201 MENA ST, MENA, AR 71953-4280
(479) 394-2332
(479) 437-3708
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
5303
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
450463188002
BLUE CROSS BLUE SHIELD
OK
Enumeration date
08/07/2006
Last updated
04/14/2008
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