Organization
ORTHODENTAL PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOSEPH A WILSON DMD, MSD (OWNER)
(505) 325-8858
Entity
Organization
Contact information
Practice address
1748 W MALONEY AVE, GALLUP, NM 87301-3333
(505) 863-8100
(505) 863-8064
Mailing address
1748 W MALONEY AVE, GALLUP, NM 87301-3333
(505) 863-8100
(505) 863-8064
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DD3399
NM
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
DD3399
NM
Other
Enumeration date
03/12/2013
Last updated
03/12/2013
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