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NPI Code Detail

MEDICARE: HAILEE BRIELLE WILSON DMD

MEDICARE: HAILEE BRIELLE WILSON DMD
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
1390200000XStudent in an Organized Health Care Education/Training Program
2122300000XDentistDN26810FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1750963062
Entity Type Code : Individual
Provider Name (Legal Business Name) : HAILEE BRIELLE WILSON DMD
Provider Business Mailing Address
First Line : 109 W FORTUNE ST APT 2417
Second Line :
City : TAMPA
State : FL
Zip : 33602-3233
Country : US
Telephone Number : 702-569-0898
Fax Number :
Provider Business Practice Location Address
First Line : 801 E BAKER ST
Second Line :
City : PLANT CITY
State : FL
Zip : 33563-3652
Country : US
Telephone Number : 813-653-6100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/26/2021
Last Update Date : 07/14/2022

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