Provider Demographics
NPI:1770101032
Name:WILSON, BRETT M (DDS)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:M
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 1:2999 CORPORATE LN
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8478
Mailing Address - Country:US
Mailing Address - Phone:757-922-8110
Mailing Address - Fax:757-922-8184
Practice Address - Street 1:2999 CORPORATE LN
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8478
Practice Address - Country:US
Practice Address - Phone:757-922-8110
Practice Address - Fax:757-922-8184
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417013122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist