Provider Demographics
NPI:1730254939
Name:WILSON, AMY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LEE
Other - Last Name:POLK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:417 UNIVERSITY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2560
Mailing Address - Country:US
Mailing Address - Phone:719-846-7387
Mailing Address - Fax:719-846-6297
Practice Address - Street 1:417 UNIVERSITY ST STE 1
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2560
Practice Address - Country:US
Practice Address - Phone:719-846-7387
Practice Address - Fax:719-846-6297
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7109122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7109OtherLICENSE #