Healthcare Provider Details

I. General information

NPI: 1952462756
Provider Name (Legal Business Name): EDWARD WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23680 US HIGHWAY 19 N
CLEARWATER FL
33765-1571
US

IV. Provider business mailing address

1770 N WICKHAM RD
MELBOURNE FL
32935-8122
US

V. Phone/Fax

Practice location:
  • Phone: 727-799-1010
  • Fax: 727-799-6909
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN11750
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: