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General NPI Number Information
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NPI Number | 1023793007
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Entity Type | Individual
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Provider Name | ZACHARY WILSON DMD
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Gender | Male
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Dates
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Enumeration Date | 06/19/2023
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Last Update Date | 06/19/2023
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Provider Practice Location Address
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Address Line | 171 PRICE RD
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City | FAYETTEVILLE
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State | GA
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Zip | 30215-2016
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Country | US
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Telephone | 770-460-9795
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 38
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-0038
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 124058
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License Number State | GA
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