Provider Demographics
NPI:1487929410
Name:WILSON, DAVID BRIAN (DMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BRIAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6669
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-6669
Mailing Address - Country:US
Mailing Address - Phone:970-949-4433
Mailing Address - Fax:
Practice Address - Street 1:82 E BEAVER CREEK BLVD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620-6669
Practice Address - Country:US
Practice Address - Phone:970-949-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105999122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist