Healthcare Provider Details

I. General information

NPI: 1083867584
Provider Name (Legal Business Name): D NEIL WILSON D.D.S. M.S. PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 35TH AVE SUITE B
VERO BEACH FL
32960-2421
US

IV. Provider business mailing address

2025 35TH AVE SUITE B
VERO BEACH FL
32960-2421
US

V. Phone/Fax

Practice location:
  • Phone: 772-299-4179
  • Fax: 772-299-4577
Mailing address:
  • Phone: 772-299-4179
  • Fax: 772-299-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN14498
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN16531
License Number StateFL

VIII. Authorized Official

Name: DR. GLENDA M CALEY
Title or Position: SECRETARY
Credential:
Phone: 772-299-4179