Provider Demographics
NPI:1144291477
Name:WILSON, KATHI ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:KATHI
Middle Name:ANN
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 1:4820 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3785
Mailing Address - Country:US
Mailing Address - Phone:616-454-1482
Mailing Address - Fax:616-454-4422
Practice Address - Street 1:4820 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3785
Practice Address - Country:US
Practice Address - Phone:616-454-1482
Practice Address - Fax:855-536-4347
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI17948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist