MEDICARE: DR. STACY RONALD WILKERSON 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	DS7116	TN

General Provider Information

NPI Number	:	1093703928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY RONALD WILKERSON DDS

Provider Business Mailing Address
First Line	:	1480 FLORENCE RD
Second Line	:
City	:	SAVANNAH
State	:	TN
Zip	:	38372-5205
Country	:	US
Telephone Number	:	731-925-5396
Fax Number	:	731-925-5349

Provider Business Practice Location Address
First Line	:	1480 FLORENCE RD
Second Line	:
City	:	SAVANNAH
State	:	TN
Zip	:	38372-5205
Country	:	US
Telephone Number	:	731-925-5396
Fax Number	:	731-925-5349

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

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	07/08/2007

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