Provider Demographics
NPI:1780390807
Name:WILSON, GARRETT LEE (DMD)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:LEE
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 1:1240 CLEO AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-2342
Mailing Address - Country:US
Mailing Address - Phone:502-602-3748
Mailing Address - Fax:
Practice Address - Street 1:1606 W MCCLAIN AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-1161
Practice Address - Country:US
Practice Address - Phone:812-414-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014107A1223G0001X
TX408691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice