Provider Demographics
NPI:1437321742
Name:WILSON, ANTIONETTE C (DDS)
Entity Type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2127 E VICTORY DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-3917
Mailing Address - Country:US
Mailing Address - Phone:912-443-6013
Mailing Address - Fax:912-443-6014
Practice Address - Street 1:2127 E VICTORY DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-3917
Practice Address - Country:US
Practice Address - Phone:912-443-6013
Practice Address - Fax:912-443-6014
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10005751223G0001X
VA04014115801223G0001X
MD139701223G0001X
GADN0136951223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2039744OtherUNITED CONCORDIA
GA428641977AMedicaid
SCZG3695Medicaid