Provider Demographics
NPI:1437239357
Name:WILSON, MARK A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
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 1:400 DUNCAN STATION RD
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15135-3333
Mailing Address - Country:US
Mailing Address - Phone:412-751-7710
Mailing Address - Fax:412-751-8427
Practice Address - Street 1:400 DUNCAN STATION RD
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15135-3333
Practice Address - Country:US
Practice Address - Phone:412-751-7710
Practice Address - Fax:412-751-8427
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-021859-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice