Provider Demographics
NPI:1649293531
Name:WILSON, KEVIN DREW (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DREW
Last Name:WILSON
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 1:154 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03055-4759
Mailing Address - Country:US
Mailing Address - Phone:603-673-3332
Mailing Address - Fax:603-672-5844
Practice Address - Street 1:154 ELM ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:NH
Practice Address - Zip Code:03055-4759
Practice Address - Country:US
Practice Address - Phone:603-673-3332
Practice Address - Fax:603-672-5844
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH30081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30300251Medicaid