Provider Demographics
NPI:1841417706
Name:WILSON, J. BRAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:BRAD
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:BRAD
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:288 NORTHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1212
Mailing Address - Country:US
Mailing Address - Phone:812-482-1855
Mailing Address - Fax:812-634-6833
Practice Address - Street 1:288 NORTHWOOD AVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1212
Practice Address - Country:US
Practice Address - Phone:812-482-1855
Practice Address - Fax:812-634-6833
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN82441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice