Provider Demographics
NPI:1679564405
Name:JAMES G WILSON DMD PA
Entity Type:Organization
Organization Name:JAMES G WILSON DMD PA
Other - Org Name:TAMPA BAY PERIODONTICS AND IMPLANT DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-251-0770
Mailing Address - Street 1:1810 S MACDILL AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5901
Mailing Address - Country:US
Mailing Address - Phone:813-251-0770
Mailing Address - Fax:813-251-0771
Practice Address - Street 1:1810 S MACDILL AVE
Practice Address - Street 2:STE 2
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5901
Practice Address - Country:US
Practice Address - Phone:813-251-0770
Practice Address - Fax:813-251-0771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN135371223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty