Provider Demographics
NPI:1558484568
Name:WILSON, EDWARD JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHN
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:PO BOX 221514
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93922-1514
Mailing Address - Country:US
Mailing Address - Phone:831-624-2203
Mailing Address - Fax:
Practice Address - Street 1:26365 CARMEL RANCHO BLVD
Practice Address - Street 2:A
Practice Address - City:CARMEL
Practice Address - State:CA
Practice Address - Zip Code:93923-8744
Practice Address - Country:US
Practice Address - Phone:831-624-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice