MEDICARE: DR. JAMES GORDON WILSON II D.M.D.

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	1223P0300X	Periodontics	DN0013537	FL

General Provider Information

NPI Number	:	1356757470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES GORDON WILSON II D.M.D.

Provider Business Mailing Address
First Line	:	1810 S MACDILL AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5960
Country	:	US
Telephone Number	:	813-251-0770
Fax Number	:	813-251-0771

Provider Business Practice Location Address
First Line	:	1810 S MACDILL AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5960
Country	:	US
Telephone Number	:	813-251-0770
Fax Number	:	813-251-0771

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

Provider Enumeration Date	:	07/09/2014
Last Update Date	:	07/09/2014

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