Provider Demographics
NPI:1851535777
Name:WILSON, PATRICIA (DDS)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
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 1:1116B BEVILLE RD
Mailing Address - Street 2:VILLAGE PLAZA
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5743
Mailing Address - Country:US
Mailing Address - Phone:386-226-2268
Mailing Address - Fax:
Practice Address - Street 1:1116B BEVILLE RD
Practice Address - Street 2:VILLAGE PLAZA
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5743
Practice Address - Country:US
Practice Address - Phone:386-226-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0012380122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist