Gary Alan Wilson, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

104357 Issued in CO

Practice address

Highway 264, Milepost 388
Polacca, AZ 86042-6042

Phone

(928) 737-6000

Fax

(928) 737-6168

NPI assigned

Aug 3, 2005

Last updated

Aug 8, 2012By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1123027200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1344384000000",
    "number": "1285635946",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "HIGHWAY 264, MP 388",
            "city": "POLACCA",
            "state": "AZ",
            "postal_code": "86042",
            "telephone_number": "928-737-6000",
            "fax_number": "928-737-6168"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "HIGHWAY 264, MILEPOST 388",
            "city": "POLACCA",
            "state": "AZ",
            "postal_code": "860426042",
            "telephone_number": "928-737-6000",
            "fax_number": "928-737-6168"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILSON",
        "first_name": "GARY",
        "middle_name": "ALAN",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-08-03",
        "last_updated": "2012-08-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CO",
            "license": "104357",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Darren Vicenti, MD
• Kelly Anne Vitz, P.T.
• Claudia Gail Von Hendricks, DDS
• Diane Renee Weidley, RDH
• Ruth Ana Williams, RDH
• Theresa Ann Wilson, LCSW
• Biau Wong, PHARMD
• Jessica Wright

• General Practice Dentistry in Polacca, AZ
• Providers in Polacca, AZ by specialty
• General Practice Dentistry in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.