=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952438285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRY COUNTY ORAL & MAXILLOFACIAL SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5615 WILLIAM FLYNN HWY
-----------------------------------------------------
City | GIBSONIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15044-9553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-444-4777
-----------------------------------------------------
Fax | 724-444-5770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5615 WILLIAM FLYNN HWY
-----------------------------------------------------
City | GIBSONIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15044-9553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-444-4777
-----------------------------------------------------
Fax | 724-444-5770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NICHOLAS A WILSON
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 724-444-4777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DS026612L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------