MEDICARE: DR. ALLYSON N WILSON D.D.S.

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	NC8469	NC

General Provider Information

NPI Number	:	1215120415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALLYSON N WILSON D.D.S.

Provider Business Mailing Address
First Line	:	1000 SOUTHPARK BLVD
Second Line	:	SUITE C
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-5072
Country	:	US
Telephone Number	:	336-788-5073
Fax Number	:	336-788-1699

Provider Business Practice Location Address
First Line	:	1000 SOUTHPARK BLVD
Second Line	:	SUITE C
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-5072
Country	:	US
Telephone Number	:	336-788-5073
Fax Number	:	336-788-1699

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

Provider Enumeration Date	:	08/21/2007
Last Update Date	:	08/21/2007

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