Provider Demographics
NPI:1700957354
Name:WILSON, JAMES KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:KENNETH
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10404 MANLY
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517
Mailing Address - Country:US
Mailing Address - Phone:919-933-1646
Mailing Address - Fax:919-933-3739
Practice Address - Street 1:121 S ESTES DRIVE
Practice Address - Street 2:SUITE 205C
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516
Practice Address - Country:US
Practice Address - Phone:919-928-0105
Practice Address - Fax:919-928-0630
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC41571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7999405Medicaid