Provider Demographics
NPI:1164111084
Name:WILSON, LUKE TYLER JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:LUKE
Middle Name:TYLER JOHN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 MACGREGOR DOWNS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5925
Mailing Address - Country:US
Mailing Address - Phone:704-995-2946
Mailing Address - Fax:
Practice Address - Street 1:141 BLOWING ROCK BLVD
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-4401
Practice Address - Country:US
Practice Address - Phone:828-394-3197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC137101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty