Provider Demographics
NPI:1962634816
Name:SOUTHVIEW DENTISTRY
Entity Type:Organization
Organization Name:SOUTHVIEW DENTISTRY
Other - Org Name:SOUTH END DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-333-4760
Mailing Address - Street 1:2201 SOUTH BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6204
Mailing Address - Country:US
Mailing Address - Phone:704-333-4760
Mailing Address - Fax:704-333-1830
Practice Address - Street 1:2201 SOUTH BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-6204
Practice Address - Country:US
Practice Address - Phone:704-333-4760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8162122300000X, 1223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1841330768OtherNPI
1568522183OtherNPI