Healthcare Provider Details

I. General information

NPI: 1104220334
Provider Name (Legal Business Name): MARION N WILSON JR., DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 22ND ST
OLD HICKORY TN
37138-2502
US

IV. Provider business mailing address

PO BOX 511
OLD HICKORY TN
37138-0511
US

V. Phone/Fax

Practice location:
  • Phone: 615-847-3088
  • Fax: 615-847-8479
Mailing address:
  • Phone: 615-847-3088
  • Fax: 615-847-8479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4168
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1588674519
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerNPI
# 2
Identifier1518374271
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerNPI

VIII. Authorized Official

Name: MRS. KERMA JO WILSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 615-847-3088