Healthcare Provider Details

I. General information

NPI: 1568674380
Provider Name (Legal Business Name): MATTHEW T WILSON DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 10/07/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 MDG, UNIT 3215, RAMSTEIN AB
APO AE
09094
US

IV. Provider business mailing address

86 MDG, UNIT 3215, RAMSTEIN AB
APO AE
09094
US

V. Phone/Fax

Practice location:
  • Phone: 240-612-3900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16745
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberD0090793
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number16745
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: