Provider Demographics
NPI:1861684722
Name:WILSON, JOHN MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:WILSON
Suffix:
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 1:110 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-1715
Mailing Address - Country:US
Mailing Address - Phone:850-547-9290
Mailing Address - Fax:850-547-4181
Practice Address - Street 1:110 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-1715
Practice Address - Country:US
Practice Address - Phone:850-547-9290
Practice Address - Fax:850-547-4181
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18106122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist