Healthcare Provider Details

I. General information

NPI: 1962634816
Provider Name (Legal Business Name): SOUTHVIEW DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 SOUTH BLVD SUITE 210
CHARLOTTE NC
28203-6204
US

IV. Provider business mailing address

2201 SOUTH BLVD SUITE 210
CHARLOTTE NC
28203-6204
US

V. Phone/Fax

Practice location:
  • Phone: 704-333-4760
  • Fax:
Mailing address:
  • Phone: 704-333-4760
  • Fax: 704-333-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8162
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8162
License Number StateNC

VIII. Authorized Official

Name: DR. MICHEAL SCOTT WILSON
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 704-333-4760