Provider Demographics
NPI:1104901107
Name:WILSON, THOMAS WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WAYNE
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC41321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8999418Medicaid