MEDICARE: DR. CONSTANCE LYNN WILSON D.M.D.

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	122300000X	Dentist	DS037648	PA

General Provider Information

NPI Number	:	1205085776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONSTANCE LYNN WILSON D.M.D.

Provider Business Mailing Address
First Line	:	222 JPM RD
Second Line	:
City	:	LEWISBURG
State	:	PA
Zip	:	17837-9340
Country	:	US
Telephone Number	:	570-524-0600
Fax Number	:	570-524-0296

Provider Business Practice Location Address
First Line	:	222 JPM RD
Second Line	:
City	:	LEWISBURG
State	:	PA
Zip	:	17837-9340
Country	:	US
Telephone Number	:	570-524-0600
Fax Number	:	570-524-0296

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

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	09/09/2008

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