Provider Demographics
NPI:1447511159
Name:WILSON, GRAHAM H (DDS)
Entity type:Individual
Prefix:
First Name:GRAHAM
Middle Name:H
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:PO BOX 71930
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23255-1930
Mailing Address - Country:US
Mailing Address - Phone:804-354-1600
Mailing Address - Fax:804-354-1607
Practice Address - Street 1:8503 PATTERSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-6442
Practice Address - Country:US
Practice Address - Phone:804-354-1600
Practice Address - Fax:804-354-1607
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014151471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery