Provider Demographics
NPI:1407933625
Name:WILSON, LISA G (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:G
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 1:5470 CALDWELL MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242
Mailing Address - Country:US
Mailing Address - Phone:205-995-8084
Mailing Address - Fax:205-995-8156
Practice Address - Street 1:5470 CALDWELL MILL ROAD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242
Practice Address - Country:US
Practice Address - Phone:205-995-8084
Practice Address - Fax:205-995-8156
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4416122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist