Provider Demographics
NPI:1134785165
Name:WILSTON, ETHAN C (DMD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:C
Last Name:WILSTON
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 1:2130 S EAGLE RD # 2132
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1579
Mailing Address - Country:US
Mailing Address - Phone:570-404-5625
Mailing Address - Fax:
Practice Address - Street 1:2130 S EAGLE RD # 2132
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1579
Practice Address - Country:US
Practice Address - Phone:215-860-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042392122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist