Healthcare Provider Details

I. General information

NPI: 1346294063
Provider Name (Legal Business Name): BRUCE TAYLOR WILSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N 12TH ST
MIDDLESBORO KY
40965-1987
US

IV. Provider business mailing address

PO BOX 1786
MIDDLESBORO KY
40965-3786
US

V. Phone/Fax

Practice location:
  • Phone: 606-248-1808
  • Fax: 859-823-4137
Mailing address:
  • Phone: 606-248-1808
  • Fax: 606-248-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number5811
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5811
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: