Provider Demographics
NPI:1730286543
Name:WILSON, FELICIA DOLORES (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:FELICIA
Middle Name:DOLORES
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 WEST GRAND BLVD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-309-0175
Mailing Address - Fax:
Practice Address - Street 1:3031 WEST GRAND BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-309-0175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI161051223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics