Healthcare Provider Details

I. General information

NPI: 1336150754
Provider Name (Legal Business Name): MICHAEL BRUCE WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 5TH STREET FULTON STATE HOSPITAL
FULTON MO
65251
US

IV. Provider business mailing address

600 E 5TH ST
FULTON MO
65251-1753
US

V. Phone/Fax

Practice location:
  • Phone: 573-592-4100
  • Fax: 573-592-3023
Mailing address:
  • Phone: 573-592-4100
  • Fax: 573-592-3023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number014306
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: