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General NPI Number Information
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NPI Number | 1578991162
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Entity Type | Organization
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Legal Business Name | MICHAEL P. WILSON, DDS, INC
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Dates
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Enumeration Date | 10/17/2013
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Last Update Date | 10/17/2013
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Provider Practice Location Address
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Address Line | 7677 CENTER AVE SUITE 210
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92647-3074
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Country | US
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Telephone | 607-238-1280
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Fax | 607-238-1286
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Provider Business Mailing Address
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Address Line | 30 W STATE ST
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City | BINGHAMTON
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State | NY
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Zip | 13901-2332
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Country | US
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Telephone | 607-238-1280
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Fax | 607-238-1286
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Authorized Official
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Title or Position | OWNER-PRESIDENT
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Name | DR. MICHAEL P WILSON
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Credential | DDS
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Telephone | 607-238-1280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 62234
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License Number State | CA
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