Provider Demographics
NPI:1306920517
Name:WILSON, NOAH R III
Entity type:Individual
Prefix:DR
First Name:NOAH
Middle Name:R
Last Name:WILSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:N.
Other - Middle Name:ROUSE
Other - Last Name:WILSON
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 940
Mailing Address - Street 2:
Mailing Address - City:PITTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27312-0940
Mailing Address - Country:US
Mailing Address - Phone:919-542-3502
Mailing Address - Fax:919-542-4719
Practice Address - Street 1:767 WEST STREET
Practice Address - Street 2:
Practice Address - City:PITTSBORO
Practice Address - State:NC
Practice Address - Zip Code:27312
Practice Address - Country:US
Practice Address - Phone:919-542-3502
Practice Address - Fax:919-542-4719
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC54651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8999413Medicaid