Provider Demographics
NPI:1699061598
Name:WILSON, BRADLEY PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:PAUL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 BROOKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-3263
Mailing Address - Country:US
Mailing Address - Phone:858-220-3257
Mailing Address - Fax:
Practice Address - Street 1:530 LOMAS SANTA FE DR STE 2
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1350
Practice Address - Country:US
Practice Address - Phone:858-794-9994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA611951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice