Healthcare Provider Details

I. General information

NPI: 1114299047
Provider Name (Legal Business Name): CAROL A. WILSON, DMD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE ST
NICHOLASVILLE KY
40356-1002
US

IV. Provider business mailing address

100 LAKE ST
NICHOLASVILLE KY
40356-1002
US

V. Phone/Fax

Practice location:
  • Phone: 859-885-5703
  • Fax: 859-885-5703
Mailing address:
  • Phone: 859-885-5703
  • Fax: 859-885-5703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8377
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8377
License Number StateKY

VIII. Authorized Official

Name: DR. CAROL ANN WILSON
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 859-885-5703