Provider Demographics
NPI:1750542973
Name:WILSON, MICHAEL RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
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 1:1401 BLIZZARD DR
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-6422
Mailing Address - Country:US
Mailing Address - Phone:304-420-0922
Mailing Address - Fax:304-420-0924
Practice Address - Street 1:1401 BLIZZARD DR
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-6422
Practice Address - Country:US
Practice Address - Phone:304-420-0922
Practice Address - Fax:304-420-0924
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice