Provider Demographics
NPI:1447425798
Name:WILSON, JEFFREY JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOSEPH
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 1:1542 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309
Mailing Address - Country:US
Mailing Address - Phone:518-370-5234
Mailing Address - Fax:518-372-4000
Practice Address - Street 1:1542 UNION ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309
Practice Address - Country:US
Practice Address - Phone:518-370-5234
Practice Address - Fax:518-372-4000
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030221122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00585460Medicaid