Provider Demographics
NPI:1891144622
Name:WILSON, DEIDRE SMITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEIDRE
Middle Name:SMITH
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:DEIDRE
Other - Middle Name:MECHELE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:195 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2659
Mailing Address - Country:US
Mailing Address - Phone:276-228-8571
Mailing Address - Fax:276-228-8571
Practice Address - Street 1:195 E SPRING ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2659
Practice Address - Country:US
Practice Address - Phone:276-228-8571
Practice Address - Fax:276-228-8571
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401415246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist