Provider Demographics
NPI:1902892540
Name:WILSON, DAVID LEE (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
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 1:41253 12TH ST W
Mailing Address - Street 2:SUITE C
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-1413
Mailing Address - Country:US
Mailing Address - Phone:661-266-8840
Mailing Address - Fax:
Practice Address - Street 1:41253 12TH ST W
Practice Address - Street 2:SUITE C
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-1413
Practice Address - Country:US
Practice Address - Phone:661-266-8840
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD257781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T79362Medicare UPIN