Active NPI
Mark M Wilson, D.D.S.
- Periodontics
- Minneapolis, MN
National Provider Identifier
1588735823
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 8580
- Practice address
- 825 Nicollet Mall
Suite 210
Minneapolis, MN 55402-2606 - Phone
- (612) 332-0869
- Fax
- (612) 332-2891
- NPI assigned
- Nov 10, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 8580 | MN | Primary |
Addresses
Primary practice location
825 Nicollet Mall
Suite 210
Minneapolis, MN 55402-2606
Mailing address
825 Nicollet Mall
Suite 210
Minneapolis, MN 55402-2606
Phone (612) 332-0869
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Dec 29, 2017 through Dec 29, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 8580 | MN | MD | Periodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1163116800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1588735823",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "825 NICOLLET MALL",
"address_2": "SUITE 210",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554022606",
"telephone_number": "612-332-0869",
"fax_number": "612-332-2891"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "825 NICOLLET MALL",
"address_2": "SUITE 210",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554022606",
"telephone_number": "612-332-0869",
"fax_number": "612-332-2891"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILSON",
"first_name": "MARK",
"middle_name": "M",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-11-10",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "MN",
"license": "8580",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Minneapolis, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.