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General NPI Number Information
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NPI Number | 1003278367
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Entity Type | Organization
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Legal Business Name | WILSON FAMILY DENTISTRY
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Dates
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Enumeration Date | 03/25/2016
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Last Update Date | 03/25/2016
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Provider Practice Location Address
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Address Line | 710 FEDERAL DR
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City | SELMER
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State | TN
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Zip | 38375-1876
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Country | US
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Telephone | 731-645-7506
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Fax | 731-645-5660
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Provider Business Mailing Address
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Address Line | 710 FEDERAL DR
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City | SELMER
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State | TN
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Zip | 38375-1876
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Country | US
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Telephone | 731-645-7506
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Fax | 731-645-5660
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CHRISTINA KING
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Credential |
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Telephone | 731-645-7506
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3832
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License Number State | TN
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