MEDICARE: DR. WILTON A GUILLORY JR. DDS

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	2647	LA

General Provider Information

NPI Number	:	1386634186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILTON A GUILLORY JR. DDS

Provider Business Mailing Address
First Line	:	2227 WORLEY DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-3631
Country	:	US
Telephone Number	:	318-445-4870
Fax Number	:	318-473-8289

Provider Business Practice Location Address
First Line	:	2227 WORLEY DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-3631
Country	:	US
Telephone Number	:	318-445-4870
Fax Number	:	318-473-8289

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

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	07/08/2007

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