Provider Demographics
NPI:1407889223
Name:WILSON, WILLIAM T (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:T
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 1:108 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-1922
Mailing Address - Country:US
Mailing Address - Phone:251-928-0620
Mailing Address - Fax:251-928-1359
Practice Address - Street 1:108 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-1922
Practice Address - Country:US
Practice Address - Phone:251-928-0620
Practice Address - Fax:251-928-1359
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL34661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL03142OtherBLUE CROSS BLUE SHIELD
AL1906760OtherUNITED CONCORDIA