MEDICARE: DR. RALPH W. WILSON DDS

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	1223G0001X	General Practice Dentistry	3214	LA

General Provider Information

NPI Number	:	1083633861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RALPH W. WILSON DDS

Provider Business Mailing Address
First Line	:	1607 MARTENS DR
Second Line	:
City	:	HAMMOND
State	:	LA
Zip	:	70401-1619
Country	:	US
Telephone Number	:	985-345-6094
Fax Number	:	985-345-0108

Provider Business Practice Location Address
First Line	:	1607 MARTENS DR
Second Line	:
City	:	HAMMOND
State	:	LA
Zip	:	70401-1619
Country	:	US
Telephone Number	:	985-345-6094
Fax Number	:	985-345-0108

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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