Healthcare Provider Details

I. General information

NPI: 1730286543
Provider Name (Legal Business Name): FELICIA DOLORES WILSON DDS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 WEST GRAND BLVD SUITE 360
DETROIT MI
48202
US

IV. Provider business mailing address

3031 WEST GRAND BLVD SUITE 360
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 313-309-0175
  • Fax:
Mailing address:
  • Phone: 313-309-0175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number16105
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: