Provider Demographics
NPI:1437446838
Name:WILSON, KATHRYN LEIGH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 MERRICK ROAD
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563
Mailing Address - Country:US
Mailing Address - Phone:516-561-1000
Mailing Address - Fax:
Practice Address - Street 1:175 BEACH 121ST ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-1960
Practice Address - Country:US
Practice Address - Phone:607-368-5396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist