Healthcare Provider Details

I. General information

NPI: 1518194901
Provider Name (Legal Business Name): ADRIAN JOHNSTON WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 RIDGE VIEW LN
LAUREL MD
20707-6278
US

IV. Provider business mailing address

14300 RIDGE VIEW LN
LAUREL MD
20707-6278
US

V. Phone/Fax

Practice location:
  • Phone: 443-280-0968
  • Fax:
Mailing address:
  • Phone: 443-280-0968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14704
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: