Provider Demographics
NPI:1679627137
Name:WILSON, JAMES SHERRILL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:SHERRILL
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 1:426 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1451
Mailing Address - Country:US
Mailing Address - Phone:304-845-7755
Mailing Address - Fax:304-845-7010
Practice Address - Street 1:426 8TH ST
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1451
Practice Address - Country:US
Practice Address - Phone:304-845-7755
Practice Address - Fax:304-845-7010
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136162000Medicaid