Provider Demographics
NPI:1568522183
Name:WILSON, MICHAEL SCOTT (DDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N TRYON ST
Mailing Address - Street 2:LTCA SUITE B 220 231
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202
Mailing Address - Country:US
Mailing Address - Phone:704-473-4335
Mailing Address - Fax:
Practice Address - Street 1:4444 STEEPLETON WAY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215
Practice Address - Country:US
Practice Address - Phone:704-473-4335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904309Medicaid
NC8192OtherDENTAL STATE BOARD