Provider Demographics
NPI:1083867584
Name:D NEIL WILSON D.D.S. M.S. PA
Entity Type:Organization
Organization Name:D NEIL WILSON D.D.S. M.S. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-299-4179
Mailing Address - Street 1:2025 35TH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-2421
Mailing Address - Country:US
Mailing Address - Phone:772-299-4179
Mailing Address - Fax:772-299-4577
Practice Address - Street 1:2025 35TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-2421
Practice Address - Country:US
Practice Address - Phone:772-299-4179
Practice Address - Fax:772-299-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN144981223E0200X
FLDN165311223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty