Provider Demographics
NPI:1861592529
Name:WILSON, BERNADETTE L (DDS MD)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2728
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:920-405-5388
Practice Address - Street 1:430 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-5115
Practice Address - Country:US
Practice Address - Phone:920-431-0345
Practice Address - Fax:920-431-0567
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22351223S0112X
MT11198204E00000X
WI5239204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33761400Medicaid
WI33761400Medicaid
H05328Medicare UPIN