Provider Demographics
NPI:1184680134
Name:WILSON, JAMES L (DMD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:SC
Mailing Address - Zip Code:29657-1009
Mailing Address - Country:US
Mailing Address - Phone:864-843-3742
Mailing Address - Fax:864-843-3744
Practice Address - Street 1:207 W FRONT ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:SC
Practice Address - Zip Code:29657-1009
Practice Address - Country:US
Practice Address - Phone:864-843-3742
Practice Address - Fax:864-843-3744
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ31449Medicaid