Provider Demographics
NPI:1598223000
Name:PETER JOHN WILSON DMD PLLC
Entity Type:Organization
Organization Name:PETER JOHN WILSON DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-780-9747
Mailing Address - Street 1:4 PORTLAND AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-6508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 YORK ST
Practice Address - Street 2:
Practice Address - City:YORK HARBOR
Practice Address - State:ME
Practice Address - Zip Code:03911
Practice Address - Country:US
Practice Address - Phone:207-363-2166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty