Provider Demographics
NPI:1205047859
Name:WILSON, JOHN III
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WILSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20747-4701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7610 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:MD
Practice Address - Zip Code:20747-4701
Practice Address - Country:US
Practice Address - Phone:301-568-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD130771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice