Provider Demographics
NPI:1023851615
Name:WILSON, LAUREN BUNCH (DDS)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:BUNCH
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 2ND AVE S APT 1604
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4758
Mailing Address - Country:US
Mailing Address - Phone:252-333-0050
Mailing Address - Fax:
Practice Address - Street 1:334 2ND AVE S APT 1604
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4758
Practice Address - Country:US
Practice Address - Phone:252-333-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM2786122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist