Provider Demographics
NPI:1528158680
Name:WILSON, ALDOUS B (DDS)
Entity type:Individual
Prefix:
First Name:ALDOUS
Middle Name:B
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 1:552 WOODBERRY DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-2719
Mailing Address - Country:US
Mailing Address - Phone:404-993-4721
Mailing Address - Fax:
Practice Address - Street 1:1257 BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1973
Practice Address - Country:US
Practice Address - Phone:404-993-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0119471223G0001X
SC36511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00809025BMedicaid