Healthcare Provider Details

I. General information

NPI: 1154265593
Provider Name (Legal Business Name): NICOLE ANNE WILSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 BERKSHIRE BLVD STE 950
WYOMISSING PA
19610-1264
US

IV. Provider business mailing address

1075 BERKSHIRE BLVD STE 950
WYOMISSING PA
19610-1264
US

V. Phone/Fax

Practice location:
  • Phone: 610-678-2175
  • Fax:
Mailing address:
  • Phone: 610-678-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS045658
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: