Provider Demographics
NPI:1629754080
Name:WILSON, MARK DORSEY
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DORSEY
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 WICKLOW RD
Mailing Address - Street 2:
Mailing Address - City:CAMPOBELLO
Mailing Address - State:SC
Mailing Address - Zip Code:29322-8423
Mailing Address - Country:US
Mailing Address - Phone:864-266-8526
Mailing Address - Fax:
Practice Address - Street 1:1730 SOUTH CAROLINA - 14
Practice Address - Street 2:
Practice Address - City:LANDRUM
Practice Address - State:SC
Practice Address - Zip Code:29356
Practice Address - Country:US
Practice Address - Phone:864-457-3425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD105041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice