Provider Demographics
NPI:1114299047
Name:CAROL A. WILSON, DMD, PLLC
Entity Type:Organization
Organization Name:CAROL A. WILSON, DMD, PLLC
Other - Org Name:JESSAMINE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-885-5703
Mailing Address - Street 1:100 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-1002
Mailing Address - Country:US
Mailing Address - Phone:859-885-5703
Mailing Address - Fax:859-885-5703
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8377122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100094910Medicaid