Provider Demographics
NPI:1386864528
Name:WILSON, MICHAEL JEREMY (DDS PA)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JEREMY
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CROASDAILE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2579
Mailing Address - Country:US
Mailing Address - Phone:919-383-7423
Mailing Address - Fax:919-383-3444
Practice Address - Street 1:2900 CROASDAILE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2579
Practice Address - Country:US
Practice Address - Phone:919-383-7423
Practice Address - Fax:919-383-3444
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC70881223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics