Provider Demographics
NPI:1295910719
Name:T. WAYNE WILSON, DDS, PA
Entity type:Organization
Organization Name:T. WAYNE WILSON, DDS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-636-5802
Mailing Address - Street 1:484 JAKE ALEXANDER BLVD W
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-1365
Mailing Address - Country:US
Mailing Address - Phone:704-636-5802
Mailing Address - Fax:704-637-6420
Practice Address - Street 1:484 JAKE ALEXANDER BLVD W
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1365
Practice Address - Country:US
Practice Address - Phone:704-636-5802
Practice Address - Fax:704-637-6420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4132261QD0000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty