| Doctor Name: | JOHN GORDON WILSON |
| NPI Number: | 1023347945 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | L.D. |
| License Number: | DTDO10126518 |
| Business Practice Address: | 715 Nicole Way Baker City, OR - 978146183 |
| Business Phone Number: | 5415238529 |
| Business Fax Number: | |
| Mailing Address: | 715 Nicole Way, BAKER CITY |
| State: | OR |
| Postal Code: | 978146183 |
| Phone Number: | 5415238529 |
| Fax Number: | |
| NPI Enumeration Date: | 12/24/2009 |
| NPI Last Update Date: | 02/02/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 122400000X |
| License Number: | DTDO10126518 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Denturist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |