Healthcare Provider Details

I. General information

NPI: 1487747945
Provider Name (Legal Business Name): BEVERLY A WILSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 DR. MARTIN L KING JR AVE
MOBILE AL
36603
US

IV. Provider business mailing address

451 CHARLESTON ST
MOBILE AL
36603
US

V. Phone/Fax

Practice location:
  • Phone: 251-432-4117
  • Fax: 251-964-4012
Mailing address:
  • Phone: 251-964-4011
  • Fax: 251-964-4012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberLNO3734
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: