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General NPI Number Information
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NPI Number | 1871164145
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Entity Type | Individual
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Provider Name | JOHN WILSON SR.
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Gender | Male
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Dates
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Enumeration Date | 07/07/2021
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Last Update Date | 04/05/2023
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Provider Practice Location Address
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Address Line | 4059 COLUMBIA RD
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City | MARTINEZ
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State | GA
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Zip | 30907-2221
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Country | US
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Telephone | 706-863-9445
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Fax | 706-863-7452
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Provider Business Mailing Address
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Address Line | 442 AUMOND RD
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City | AUGUSTA
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State | GA
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Zip | 30909-3561
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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 | DN122429
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License Number State | GA
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