MEDICARE: WILSON FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	3832	TN

General Provider Information

NPI Number	:	1003278367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSON FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	710 FEDERAL DR
Second Line	:
City	:	SELMER
State	:	TN
Zip	:	38375-1876
Country	:	US
Telephone Number	:	731-645-7506
Fax Number	:	731-645-5660

Provider Business Practice Location Address
First Line	:	710 FEDERAL DR
Second Line	:
City	:	SELMER
State	:	TN
Zip	:	38375-1876
Country	:	US
Telephone Number	:	731-645-7506
Fax Number	:	731-645-5660

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	CHRISTINA KING
Credential	:
Telephone Number	:	731-645-7506

Provider Enumeration Date	:	03/25/2016
Last Update Date	:	03/25/2016

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Directions to “WILSON FAMILY DENTISTRY ” Practice Location

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