MEDICARE: JEFF WILSON DDS, INC.

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

General Provider Information

NPI Number	:	1912777194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFF WILSON DDS, INC.

Provider Business Mailing Address
First Line	:	2172 ROBINSON ST
Second Line	:
City	:	OROVILLE
State	:	CA
Zip	:	95965-4937
Country	:	US
Telephone Number	:	530-534-1663
Fax Number	:

Provider Business Practice Location Address
First Line	:	2172 ROBINSON ST
Second Line	:
City	:	OROVILLE
State	:	CA
Zip	:	95965-4937
Country	:	US
Telephone Number	:	530-534-1663
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRYAN JEFFREY WILSON
Credential	:	DDS
Telephone Number	:	530-534-1663

Provider Enumeration Date	:	01/08/2024
Last Update Date	:	01/08/2024

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