Individual
SHANE A WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
110 WATSON CIR, GRAVOIS MILLS, MO 65037-4625
(763) 528-5539
Mailing address
110 WATSON CIR, GRAVOIS MILLS, MO 65037-4625
(763) 528-5539
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
2022019208
MO
Other
Enumeration date
03/24/2022
Last updated
06/06/2022
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