Provider Demographics
NPI:1972654192
Name:WILSON, MICHAEL PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W. STATE ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901
Mailing Address - Country:US
Mailing Address - Phone:607-238-1280
Mailing Address - Fax:607-238-1286
Practice Address - Street 1:289 CHENANGO ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901
Practice Address - Country:US
Practice Address - Phone:607-238-1280
Practice Address - Fax:607-238-1286
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052924122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02779028Medicaid