Provider Demographics
NPI:1891464996
Name:WILSON, SPENCER SIMON (DMD)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:SIMON
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 1:824 WILDWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-2823
Mailing Address - Country:US
Mailing Address - Phone:601-528-1321
Mailing Address - Fax:
Practice Address - Street 1:1700 6TH AVE N
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35020-4849
Practice Address - Country:US
Practice Address - Phone:205-434-2031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0006944-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice