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General NPI Number Information
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NPI Number | 1346810900
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Entity Type | Individual
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Provider Name | KRISTIN NICOLE WILSON DMD
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Gender | Female
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Dates
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Enumeration Date | 06/28/2021
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Last Update Date | 08/15/2022
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Provider Practice Location Address
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Address Line | 4070 LAVISTA RD STE 102
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City | TUCKER
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State | GA
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Zip | 30084-5228
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Country | US
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Telephone | 770-225-0723
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Fax | 770-491-0037
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Provider Business Mailing Address
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Address Line | 3897 RIVER RIDGE CT
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City | DECATUR
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State | GA
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Zip | 30034-6902
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Country | US
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Telephone | 404-906-1552
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DT-2911-0
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN122747
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License Number State | GA
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