Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | DN012912 | GA |
NPI | 1013033943 |
---|---|
Provider Name | Dr. Ron D. Wilson |
First Address | Hoschton, GA 30548-4038 |
Second Address | Hoschton, GA 30548-4038 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2007 |
Last Update Date | 04/08/2008 |