MEDICARE: T. WAYNE WILSON, DDS, PA

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	261QD0000X	Dental Clinic/Center	4132	NC

General Provider Information

NPI Number	:	1295910719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	T. WAYNE WILSON, DDS, PA

Provider Business Mailing Address
First Line	:	484 JAKE ALEXANDER BLVD W
Second Line	:
City	:	SALISBURY
State	:	NC
Zip	:	28147-1365
Country	:	US
Telephone Number	:	704-636-5802
Fax Number	:	704-637-6420

Provider Business Practice Location Address
First Line	:	484 JAKE ALEXANDER BLVD W
Second Line	:
City	:	SALISBURY
State	:	NC
Zip	:	28147-1365
Country	:	US
Telephone Number	:	704-636-5802
Fax Number	:	704-637-6420

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. THOMAS WAYNE WILSON
Credential	:	D.D.S.
Telephone Number	:	704-636-5802

Provider Enumeration Date	:	01/03/2008
Last Update Date	:	09/30/2015

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