Provider Demographics
NPI:1932297892
Name:WILSON, LARRY DON (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DON
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 1:2247 HELTON DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1063
Mailing Address - Country:US
Mailing Address - Phone:256-767-3228
Mailing Address - Fax:256-767-3240
Practice Address - Street 1:2247 HELTON DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1063
Practice Address - Country:US
Practice Address - Phone:256-767-3228
Practice Address - Fax:256-767-3240
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL34651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL63-0836903OtherTAX ID NUMBER
AL26-2988516OtherEIN