Provider Demographics
NPI:1104822394
Name:WILSON, JEFFREY DOUGLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DOUGLAS
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 1:13728 OFFICE PARK CT
Mailing Address - Street 2:
Mailing Address - City:BAYONET POINT
Mailing Address - State:FL
Mailing Address - Zip Code:34667-7144
Mailing Address - Country:US
Mailing Address - Phone:727-863-9669
Mailing Address - Fax:727-862-8907
Practice Address - Street 1:13728 OFFICE PARK CT
Practice Address - Street 2:
Practice Address - City:BAYONET POINT
Practice Address - State:FL
Practice Address - Zip Code:34667-7144
Practice Address - Country:US
Practice Address - Phone:727-863-9669
Practice Address - Fax:727-862-8907
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL146851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54987OtherBLUE CROSS BLUE SHEILD
FL539190OtherUNITED CONCORDIA