MEDICARE: DR. MICHAEL D WILSON DDS

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	1223G0001X	General Practice Dentistry	4288	NV

General Provider Information

NPI Number	:	1043450869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL D WILSON DDS

Provider Business Mailing Address
First Line	:	4230 E CHARLESTON BLVD
Second Line	:	SUITE B
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-2387
Country	:	US
Telephone Number	:	702-459-7446
Fax Number	:	702-459-8078

Provider Business Practice Location Address
First Line	:	4230 E CHARLESTON BLVD
Second Line	:	SUITE B
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-2387
Country	:	US
Telephone Number	:	702-459-7446
Fax Number	:	702-459-8078

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

Provider Enumeration Date	:	03/06/2009
Last Update Date	:	03/06/2009

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