Provider Demographics
NPI:1487747945
Name:WILSON, BEVERLY A (DDS)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 CHARLESTON ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603
Mailing Address - Country:US
Mailing Address - Phone:251-964-4011
Mailing Address - Fax:251-964-4012
Practice Address - Street 1:1303 DR. MARTIN L KING JR AVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36603
Practice Address - Country:US
Practice Address - Phone:251-432-4117
Practice Address - Fax:251-964-4012
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLNO3734122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL6314000141Medicaid
AL6314000141Medicaid
AL051554250Medicare ID - Type Unspecified