Provider Demographics
NPI:1477188654
Name:WILSON, ADRIAN S (DMD)
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40210-1368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 S 15TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210-1368
Practice Address - Country:US
Practice Address - Phone:800-787-2812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-07
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY105481223G0001X
OH30.0266841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program