MEDICARE: JOSHLYN JAMECIA WILSON

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	122300000X	Dentist	8952	SC

General Provider Information

NPI Number	:	1346761566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSHLYN JAMECIA WILSON

Provider Business Mailing Address
First Line	:	1131 RUTHERFORD RD
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29609-3905
Country	:	US
Telephone Number	:	864-271-9062
Fax Number	:

Provider Business Practice Location Address
First Line	:	1131 RUTHERFORD RD
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29609-3905
Country	:	US
Telephone Number	:	864-271-9062
Fax Number	:

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

Provider Enumeration Date	:	06/28/2017
Last Update Date	:	07/21/2022

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