Provider Demographics
NPI:1730269382
Name:WILSON, RONALD STANLEY (DMD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:STANLEY
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 1:140 MALL CONNECTOR RD
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607
Mailing Address - Country:US
Mailing Address - Phone:864-244-7135
Mailing Address - Fax:864-268-2428
Practice Address - Street 1:140 MALL CONNECTOR RD
Practice Address - Street 2:SUITE 6A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607
Practice Address - Country:US
Practice Address - Phone:864-244-7135
Practice Address - Fax:864-268-2428
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3603Medicaid