Provider Demographics
NPI:1679657886
Name:N. ROUSE WILSON, III, DDS, PA
Entity type:Organization
Organization Name:N. ROUSE WILSON, III, DDS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-542-3502
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:27312-0940
Practice Address - Country:US
Practice Address - Phone:919-542-3502
Practice Address - Fax:919-542-4719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
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?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8999413Medicaid