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General NPI Number Information
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NPI Number | 1861592529
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Entity Type | Individual
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Provider Name | BERNADETTE L WILSON DDS MD
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Gender | Female
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Dates
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Enumeration Date | 09/23/2006
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Last Update Date | 02/06/2019
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Provider Practice Location Address
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Address Line | 430 MAIN ST
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City | GREEN BAY
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State | WI
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Zip | 54301-5115
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Country | US
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Telephone | 920-431-0345
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Fax | 920-431-0567
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Provider Business Mailing Address
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Address Line | 164 N BROADWAY
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City | GREEN BAY
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State | WI
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Zip | 54303-2728
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Country | US
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Telephone | 920-490-9046
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Fax | 920-405-5388
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 2235
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 11198
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License Number State | MT
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Taxonomy #3
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 5239
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 5239
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License Number State | WI
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