Provider Demographics
NPI:1609878909
Name:WILSON, PATRICK R (DDS)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:R
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 1:6744 CLAYTON RD
Mailing Address - Street 2:STE 216
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1634
Mailing Address - Country:US
Mailing Address - Phone:314-645-1337
Mailing Address - Fax:314-645-5652
Practice Address - Street 1:6744 CLAYTON RD
Practice Address - Street 2:STE 216
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1634
Practice Address - Country:US
Practice Address - Phone:314-645-1337
Practice Address - Fax:314-645-5652
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODEN 0119211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice