Provider Demographics
NPI:1629142690
Name:WILSON, DAVID WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2862 FARRELL CRES
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1392
Mailing Address - Country:US
Mailing Address - Phone:270-684-3610
Mailing Address - Fax:270-684-3914
Practice Address - Street 1:2862 FARRELL CRES
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1392
Practice Address - Country:US
Practice Address - Phone:270-684-3610
Practice Address - Fax:270-684-3914
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist