MEDICARE: DR WILSON AND DR KRAUSE, LLC

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	19817	OH

General Provider Information

NPI Number	:	1053795294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR WILSON AND DR KRAUSE, LLC

Provider Business Mailing Address
First Line	:	8401 HOWLAND SPRINGS RD SE
Second Line	:
City	:	WARREN
State	:	OH
Zip	:	44484-3120
Country	:	US
Telephone Number	:	330-856-2177
Fax Number	:

Provider Business Practice Location Address
First Line	:	8401 HOWLAND SPRINGS RD SE
Second Line	:
City	:	WARREN
State	:	OH
Zip	:	44484-3120
Country	:	US
Telephone Number	:	330-856-2177
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. THOMAS WILSON
Credential	:
Telephone Number	:	330-856-2177

Provider Enumeration Date	:	07/17/2015
Last Update Date	:	07/17/2015

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