Provider Demographics
NPI:1164154498
Name:WILSON, MATTHEW (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:8420 HOGAN DR SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-3432
Mailing Address - Country:US
Mailing Address - Phone:256-655-4766
Mailing Address - Fax:
Practice Address - Street 1:54 TAYLOR RD SE # 9281
Practice Address - Street 2:
Practice Address - City:OWENS CROSS ROADS
Practice Address - State:AL
Practice Address - Zip Code:35763-9498
Practice Address - Country:US
Practice Address - Phone:256-536-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0007065-C1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist