Provider Demographics
NPI:1861507865
Name:WILSON, LATOYA S (DMD)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LATOYA
Other - Middle Name:RUTH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:5701 DELMAR
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-0937
Mailing Address - Country:US
Mailing Address - Phone:314-367-7848
Mailing Address - Fax:314-367-2985
Practice Address - Street 1:5701 DELMAR
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-0937
Practice Address - Country:US
Practice Address - Phone:314-367-7848
Practice Address - Fax:314-367-2985
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006024770122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist