Provider Demographics
NPI:1023423639
Name:WILSON, WYATT WILLIAM (DMD)
Entity type:Individual
Prefix:DR
First Name:WYATT
Middle Name:WILLIAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 SW HUNZIKER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2302
Mailing Address - Country:US
Mailing Address - Phone:503-941-3077
Mailing Address - Fax:503-747-7013
Practice Address - Street 1:19029 BEAVERCREEK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-9537
Practice Address - Country:US
Practice Address - Phone:503-941-3064
Practice Address - Fax:503-941-3075
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD100581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500675716Medicaid