MEDICARE: JOHN WILSON III

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	13077	MD

General Provider Information

NPI Number	:	1205047859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WILSON III

Provider Business Mailing Address
First Line	:	7610 PENNSYLVANIA AVE
Second Line	:
City	:	FORESTVILLE
State	:	MD
Zip	:	20747-4701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7610 PENNSYLVANIA AVE
Second Line	:
City	:	FORESTVILLE
State	:	MD
Zip	:	20747-4701
Country	:	US
Telephone Number	:	301-568-4800
Fax Number	:

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

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	07/08/2007

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