Provider Demographics
NPI:1669559555
Name:WILSON, JAMES L (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:L
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:PO BOX 1064
Mailing Address - Street 2:10 EAST CHURCH STREET
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24114-1064
Mailing Address - Country:US
Mailing Address - Phone:276-632-4600
Mailing Address - Fax:276-632-9549
Practice Address - Street 1:10 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-6204
Practice Address - Country:US
Practice Address - Phone:276-632-4600
Practice Address - Fax:276-632-9549
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010055811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice