Provider Demographics
NPI:1912117615
Name:MICHAEL T. WILSON, DDS, PA
Entity Type:Organization
Organization Name:MICHAEL T. WILSON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-892-7866
Mailing Address - Street 1:9620 HOLLY POINT DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-4949
Mailing Address - Country:US
Mailing Address - Phone:704-892-7866
Mailing Address - Fax:
Practice Address - Street 1:9620 HOLLY POINT DR
Practice Address - Street 2:SUITE 202
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-4949
Practice Address - Country:US
Practice Address - Phone:704-892-7866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC61001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty