Provider Demographics
NPI:1518253442
Name:WILSON, ANDREW THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:THOMAS
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 1:726 E CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5809
Mailing Address - Country:US
Mailing Address - Phone:864-332-7483
Mailing Address - Fax:
Practice Address - Street 1:190 MUTUAL DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1767
Practice Address - Country:US
Practice Address - Phone:864-222-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC70201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice