MEDICARE: DR. GORDON WILSON WOOLLARD DDS MS

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	1223E0200X	Endodontics	5361	NE

General Provider Information

NPI Number	:	1265482350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON WILSON WOOLLARD DDS MS

Provider Business Mailing Address
First Line	:	5609 MUDRY CT
Second Line	:
City	:	FORT POLK
State	:	LA
Zip	:	71459-3448
Country	:	US
Telephone Number	:	337-531-4833
Fax Number	:

Provider Business Practice Location Address
First Line	:	1840 BELLRICHARD
Second Line	:	CHESSER DENTAL CLINIC
City	:	FT POLK
State	:	LA
Zip	:	71459
Country	:	US
Telephone Number	:	337-531-4854
Fax Number	:

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/08/2007

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