Provider Demographics
NPI:1598930562
Name:WILSON, MELISSA L (D D S)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23020 HIGHLAND KNOLLS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-8347
Mailing Address - Country:US
Mailing Address - Phone:281-693-6427
Mailing Address - Fax:
Practice Address - Street 1:23020 HIGHLAND KNOLLS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-8347
Practice Address - Country:US
Practice Address - Phone:281-693-6427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice