Provider Demographics
NPI:1093776536
Name:WILSON, HERBERT SKIPPER (DMD)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:SKIPPER
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 1:4590 WOODMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2918
Mailing Address - Country:US
Mailing Address - Phone:334-271-2002
Mailing Address - Fax:334-271-4523
Practice Address - Street 1:4590 WOODMERE BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2918
Practice Address - Country:US
Practice Address - Phone:334-271-2002
Practice Address - Fax:334-271-4523
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2941174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT68851Medicare UPIN