Healthcare Provider Details

I. General information

NPI: 1679564405
Provider Name (Legal Business Name): JAMES G WILSON DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 S MACDILL AVE STE 2
TAMPA FL
33629-5901
US

IV. Provider business mailing address

1810 S MACDILL AVE STE 2
TAMPA FL
33629-5901
US

V. Phone/Fax

Practice location:
  • Phone: 813-251-0770
  • Fax: 813-251-0771
Mailing address:
  • Phone: 813-251-0770
  • Fax: 813-251-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN13537
License Number StateFL

VIII. Authorized Official

Name: DR. JAMES G WILSON
Title or Position: PRESIDENT
Credential: DMD
Phone: 813-251-0770