Provider Demographics
NPI:1104026483
Name:WILSON, MICHELLE BERGMANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:BERGMANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 KRESKY AVE
Mailing Address - Street 2:SUITE 118
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-8982
Mailing Address - Country:US
Mailing Address - Phone:360-736-1114
Mailing Address - Fax:
Practice Address - Street 1:1611 KRESKY AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8982
Practice Address - Country:US
Practice Address - Phone:360-736-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000110261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice