Provider Demographics
NPI:1619427325
Name:WILSON, ALEXIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 ROBERT FULTON DR STE 300
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-4362
Mailing Address - Country:US
Mailing Address - Phone:617-620-3320
Mailing Address - Fax:
Practice Address - Street 1:1801 ROBERT FULTON DR STE 300
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-4362
Practice Address - Country:US
Practice Address - Phone:617-620-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60672750122300000X
VA0401416901122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist