Provider Demographics
NPI:1114054541
Name:WILSON, CAROL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 KENTON CT
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-9096
Mailing Address - Country:US
Mailing Address - Phone:859-492-2735
Mailing Address - Fax:
Practice Address - Street 1:100 LAKE ST
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-1002
Practice Address - Country:US
Practice Address - Phone:859-885-5703
Practice Address - Fax:859-885-5703
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8377122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100094910Medicaid