Provider Demographics
NPI:1326664061
Name:WILSON, VALARIE D (DMD)
Entity Type:Individual
Prefix:DR
First Name:VALARIE
Middle Name:D
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 1:565 OLD FRIAR TUCK LN
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5236
Mailing Address - Country:US
Mailing Address - Phone:404-786-4207
Mailing Address - Fax:
Practice Address - Street 1:3155 ROYAL DR STE 125
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-2477
Practice Address - Country:US
Practice Address - Phone:404-612-1867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011475122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN011475OtherGEORGIA BOARD OF DENTISTRY