Provider Demographics
NPI:1619122843
Name:WILSON, ELIZABETH M
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7204 GLEN FOREST DR
Mailing Address - Street 2:SUITE #203
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3782
Mailing Address - Country:US
Mailing Address - Phone:804-282-7269
Mailing Address - Fax:804-282-7261
Practice Address - Street 1:7204 GLEN FOREST DR
Practice Address - Street 2:SUITE #203
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3782
Practice Address - Country:US
Practice Address - Phone:804-282-7269
Practice Address - Fax:804-282-7261
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014104641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice