Provider Demographics
NPI:1699759175
Name:WILSON, BRETT MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:MICHAEL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5227 S MAIN ST
Mailing Address - Street 2:STE D
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4916
Mailing Address - Country:US
Mailing Address - Phone:417-622-0004
Mailing Address - Fax:417-553-7998
Practice Address - Street 1:5227 S MAIN ST
Practice Address - Street 2:STE D
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4916
Practice Address - Country:US
Practice Address - Phone:417-622-0004
Practice Address - Fax:417-553-7998
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20050150291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry