Provider Demographics
NPI:1548549504
Name:WILSON, NICHOLAS DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:DALE
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:BUILDING 674
Mailing Address - Street 2:315 BRANNON RD
Mailing Address - City:SCHOFIELD BARRACKS
Mailing Address - State:HI
Mailing Address - Zip Code:96786
Mailing Address - Country:US
Mailing Address - Phone:808-433-8945
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE ROAD
Practice Address - Street 2:ATTN: MCDS-NH
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5000
Practice Address - Country:US
Practice Address - Phone:808-433-1021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60850122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist