Provider Demographics
NPI:1013026657
Name:WILSON, BRYAN M (DDS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MDG
Mailing Address - Street 2:UNIT 2060
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96278-2060
Mailing Address - Country:KR
Mailing Address - Phone:0118231-661-2108
Mailing Address - Fax:
Practice Address - Street 1:51 MDG
Practice Address - Street 2:UNIT 2060
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2060
Practice Address - Country:KR
Practice Address - Phone:0118231-661-2108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08321122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist