Provider Demographics
NPI:1437590486
Name:WILSON, PATRICK ROGER (DMD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:ROGER
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 1:1602 MOCKINGBIRD CT
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1552
Mailing Address - Country:US
Mailing Address - Phone:256-764-9533
Mailing Address - Fax:256-718-1013
Practice Address - Street 1:1602 MOCKINGBIRD CT
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1552
Practice Address - Country:US
Practice Address - Phone:256-764-9533
Practice Address - Fax:256-718-1013
Is Sole Proprietor?:No
Enumeration Date:2013-07-07
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD 6089 C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice