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General NPI Number Information
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NPI Number | 1275662439
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Entity Type | Organization
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Legal Business Name | DR JOHN T WILSON PC
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 07/20/2011
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Provider Practice Location Address
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Address Line | 1515 TILLMAN AVE
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City | BRUNSWICK
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State | GA
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Zip | 31520-6933
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Country | US
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Telephone | 912-262-0542
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Fax | 912-262-6538
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Provider Business Mailing Address
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Address Line | 1515 TILLMAN AVE
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City | BRUNSWICK
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State | GA
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Zip | 31520-6933
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Country | US
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Telephone | 912-262-0542
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Fax | 912-262-6538
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Authorized Official
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Title or Position | CFO
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Name | PAIGE WILSON
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Credential |
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Telephone | 912-262-0542
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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 | DNO12937
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 010583
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License Number State | GA
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