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General NPI Number Information
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NPI Number | 1396924544
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Entity Type | Organization
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Legal Business Name | BRUCE T. WILSON,D.M.D., PSC
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Dates
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Enumeration Date | 10/24/2007
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Last Update Date | 10/24/2007
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Provider Practice Location Address
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Address Line | 123 N 19TH ST
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City | MIDDLESBORO
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State | KY
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Zip | 40965-2865
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Country | US
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Telephone | 606-248-1808
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Fax | 606-248-1803
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Provider Business Mailing Address
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Address Line | 123 N 19TH ST PO BOX 1786
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City | MIDDLESBORO
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State | KY
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Zip | 40965-2865
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Country | US
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Telephone | 606-248-1808
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Fax | 606-248-1803
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRUCE TAYLOR WILSON
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Credential | DMD
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Telephone | 606-248-1808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 5811
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License Number State | KY
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