Provider Demographics
NPI:1568084663
Name:WILSON, AVERY M (DMD)
Entity Type:Individual
Prefix:DR
First Name:AVERY
Middle Name:M
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 1:412 MALCOLM DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6129
Mailing Address - Country:US
Mailing Address - Phone:410-970-0292
Mailing Address - Fax:
Practice Address - Street 1:412 MALCOLM DR STE 100
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6129
Practice Address - Country:US
Practice Address - Phone:410-970-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02819100122300000X, 1223P0300X
MD179291223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist