Provider Demographics
NPI:1366534208
Name:WILSON, RICHARD SMITH JR (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SMITH
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:BARRY
Other - Middle Name:F
Other - Last Name:SUKONECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2401 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 1A8
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3010
Mailing Address - Country:US
Mailing Address - Phone:215-765-5281
Mailing Address - Fax:215-765-7334
Practice Address - Street 1:2401 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 1A8
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3010
Practice Address - Country:US
Practice Address - Phone:215-765-5281
Practice Address - Fax:215-765-7334
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025826L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice