Provider Demographics
NPI:1386025963
Name:WILSON, BRETT ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:ALLEN
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 1:374 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-6073
Mailing Address - Country:US
Mailing Address - Phone:580-243-7865
Mailing Address - Fax:
Practice Address - Street 1:875 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-1900
Practice Address - Country:US
Practice Address - Phone:901-448-6233
Practice Address - Fax:901-448-5480
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN115061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program