Provider Demographics
NPI:1336297589
Name:WILSON, WESTON PERRY (DDS)
Entity Type:Individual
Prefix:
First Name:WESTON
Middle Name:PERRY
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 1:78 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-2521
Mailing Address - Country:US
Mailing Address - Phone:781-729-9770
Mailing Address - Fax:
Practice Address - Street 1:78 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-2521
Practice Address - Country:US
Practice Address - Phone:781-729-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14051122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist