Provider Demographics
NPI:1346810900
Name:WILSON, KRISTIN NICOLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:NICOLE
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 1:3897 RIVER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-6902
Mailing Address - Country:US
Mailing Address - Phone:404-906-1552
Mailing Address - Fax:
Practice Address - Street 1:4070 LAVISTA RD STE 102
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5228
Practice Address - Country:US
Practice Address - Phone:770-225-0723
Practice Address - Fax:770-491-0037
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-2911-0122300000X
GADN1227471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist