Healthcare Provider Details

I. General information

NPI: 1184614158
Provider Name (Legal Business Name): PAUL RICHARD WILSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 MAIN ST
WALPOLE MA
02081-2997
US

IV. Provider business mailing address

841 MAIN ST
WALPOLE MA
02081-2997
US

V. Phone/Fax

Practice location:
  • Phone: 508-660-2900
  • Fax: 508-660-0134
Mailing address:
  • Phone: 508-660-2900
  • Fax: 508-660-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number20773
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: