Provider Demographics
NPI:1295859171
Name:WILSON, DWIGHT ELWOOD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:ELWOOD
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 NW 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33127-2501
Mailing Address - Country:US
Mailing Address - Phone:305-757-0541
Mailing Address - Fax:305-757-0541
Practice Address - Street 1:4301 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-2501
Practice Address - Country:US
Practice Address - Phone:305-757-0541
Practice Address - Fax:305-757-0541
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN77651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice