Provider Demographics
NPI:1972187193
Name:WILSON, MADELINE J (DDS)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:RICKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:738 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-1328
Mailing Address - Country:US
Mailing Address - Phone:734-945-5657
Mailing Address - Fax:
Practice Address - Street 1:123 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1235
Practice Address - Country:US
Practice Address - Phone:734-475-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600919APP21122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist