Provider Demographics
NPI:1861409203
Name:WILSON, LORI S (DDS)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:S
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 1:602 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-7860
Mailing Address - Country:US
Mailing Address - Phone:757-635-0497
Mailing Address - Fax:804-733-8687
Practice Address - Street 1:3052 MCGEHEE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2203
Practice Address - Country:US
Practice Address - Phone:334-239-9704
Practice Address - Fax:334-239-9505
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0006715-C1223G0001X
VA04014111641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9179631Medicaid
VA7996766OtherAETNA
VA1335151OtherUNITED CONCORDIA
VA199459OtherBLUE CROSS/ BLUE SHIELD