Provider Demographics
NPI:1992092738
Name:WILSON, NATASHA (DDS)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 MALL PKWY STE 810
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6911
Mailing Address - Country:US
Mailing Address - Phone:770-484-4994
Mailing Address - Fax:770-484-4575
Practice Address - Street 1:8180 MALL PKWY STE 810
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-6911
Practice Address - Country:US
Practice Address - Phone:770-484-4994
Practice Address - Fax:770-484-4575
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000009326122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist