=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114040367
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM F WILSON JR. DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 DESOTO AVE EXTENDED
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-627-1181
-----------------------------------------------------
Fax | 662-627-3674
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 850 DESOTO AVE EXTENDED
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-627-1181
-----------------------------------------------------
Fax | 662-627-3674
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 210784
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------