Provider Demographics
NPI:1972701399
Name:WILSON, COREY MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:MICHAEL
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 1:6929 ASHTON ST
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-6044
Mailing Address - Country:US
Mailing Address - Phone:561-703-1783
Mailing Address - Fax:
Practice Address - Street 1:1011 FOREST HILL BLVD., SUITE 331
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-798-0825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16632122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist