Healthcare Provider Details

I. General information

NPI: 1912303561
Provider Name (Legal Business Name): RON D. WILSON DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 SHERWOOD PARK DRIVE
GAINESVILLE GA
30501-3445
US

IV. Provider business mailing address

1220 SHERWOOD PARK DRIVE
GAINESVILLE GA
30501-3445
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-0882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12912
License Number StateGA

VIII. Authorized Official

Name: DR. RON D WILSON
Title or Position: OWNER
Credential:
Phone: 770-536-0882