Provider Demographics
NPI:1841330768
Name:WILSON, KELLY BROOKS (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:BROOKS
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 TEXTILE WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1265
Mailing Address - Country:US
Mailing Address - Phone:704-564-3285
Mailing Address - Fax:
Practice Address - Street 1:2201 S BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-6208
Practice Address - Country:US
Practice Address - Phone:704-333-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice