Provider Demographics
NPI:1710345160
Name:WILSON, PAUL (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
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 1:108 MEADOWGLADE LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-6851
Mailing Address - Country:US
Mailing Address - Phone:720-936-9168
Mailing Address - Fax:
Practice Address - Street 1:4032 BALMORAL DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6402
Practice Address - Country:US
Practice Address - Phone:720-936-9168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-31
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0007020-C1223D0004X
CO002039681223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty