MEDICARE: MR. JACK ANTHONY WILSON RDHAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	HAP 299	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	299	OTHER	CA	REGISTERED DENTAL HYGIENIST IN ALTERNATIVE PRACTICE

General Provider Information

NPI Number	:	1043216807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK ANTHONY WILSON RDHAP

Provider Business Mailing Address
First Line	:	2654 STACEY WAY
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-7760
Country	:	US
Telephone Number	:	559-289-8293
Fax Number	:

Provider Business Practice Location Address
First Line	:	2654 STACEY WAY
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-7760
Country	:	US
Telephone Number	:	559-289-8293
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	07/15/2014

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