Provider Demographics
NPI:1831309319
Name:WILSON, DAVID WALLACE JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WALLACE
Last Name:WILSON
Suffix:JR
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 1:265 WINTON BLOUNT LOOP
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117
Mailing Address - Country:US
Mailing Address - Phone:334-273-7979
Mailing Address - Fax:334-273-7979
Practice Address - Street 1:265 WINTON BLOUNT LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117
Practice Address - Country:US
Practice Address - Phone:334-273-7979
Practice Address - Fax:334-273-7979
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL44741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice