Provider Demographics
NPI:1831318617
Name:WILSON, PAMELA L (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W 57TH ST
Mailing Address - Street 2:SUITE 1012
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2211
Mailing Address - Country:US
Mailing Address - Phone:212-246-4009
Mailing Address - Fax:
Practice Address - Street 1:111 W 57TH ST
Practice Address - Street 2:SUITE 1012
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2211
Practice Address - Country:US
Practice Address - Phone:212-246-4009
Practice Address - Fax:212-582-2442
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY40808-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice