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NPI Code Detail

MEDICARE: PHILLIP DUANE WILSON D.D.S.

MEDICARE: PHILLIP DUANE WILSON D.D.S.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentist16752TX
2122300000XDentistDEN4754ME

General Provider Information

NPI Number : 1215144910
Entity Type Code : Individual
Provider Name (Legal Business Name) : PHILLIP DUANE WILSON D.D.S.
Provider Business Mailing Address
First Line : 716 STEVENS AVE
Second Line :
City : PORTLAND
State : ME
Zip : 04103-2693
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 716 STEVENS AVE
Second Line :
City : PORTLAND
State : ME
Zip : 04103-2693
Country : US
Telephone Number : 207-283-0171
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/16/2007
Last Update Date : 02/10/2020

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