Healthcare Provider Details

I. General information

NPI: 1801969910
Provider Name (Legal Business Name): MYRON KEITH WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 BLUFF CITY HWY
BRISTOL TN
37620-4637
US

IV. Provider business mailing address

739 BLUFF CITY HWY
BRISTOL TN
37620-4637
US

V. Phone/Fax

Practice location:
  • Phone: 423-652-2624
  • Fax: 423-968-9471
Mailing address:
  • Phone: 423-652-2624
  • Fax: 423-968-9471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number004698
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: