Provider Demographics
NPI:1538142781
Name:WILSON, NICHOLAS A (DMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
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 1:9819 PRESIDENTIAL DR
Mailing Address - Street 2:APT 203
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-1886
Mailing Address - Country:US
Mailing Address - Phone:412-369-4494
Mailing Address - Fax:724-598-7337
Practice Address - Street 1:5615 ROUTE 8
Practice Address - Street 2:
Practice Address - City:GIBSONIA
Practice Address - State:PA
Practice Address - Zip Code:15044-9553
Practice Address - Country:US
Practice Address - Phone:724-444-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026616L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011762880012Medicaid
OH2241434Medicaid
PA0011762880022Medicaid
PA0011762880034Medicaid
PA001176288Medicaid