Healthcare Provider Details

I. General information

NPI: 1275611758
Provider Name (Legal Business Name): DENISE WILSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27300 WIXOM RD
NOVI MI
48374-1120
US

IV. Provider business mailing address

49676 TIMBER TRL
NOVI MI
48374-2162
US

V. Phone/Fax

Practice location:
  • Phone: 248-349-6379
  • Fax:
Mailing address:
  • Phone: 248-505-3214
  • Fax: 248-349-3874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002778
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: