MEDICARE: DR. JACK L WILSON D.D.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	M470	SD

General Provider Information

NPI Number	:	1497949929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK L WILSON D.D.S.

Provider Business Mailing Address
First Line	:	1721 S CLEVELAND AVE
Second Line	:	SUITE 100
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-5501
Country	:	US
Telephone Number	:	605-978-9000
Fax Number	:	605-978-9009

Provider Business Practice Location Address
First Line	:	1721 S CLEVELAND AVE
Second Line	:	SUITE 100
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-5501
Country	:	US
Telephone Number	:	605-978-9000
Fax Number	:	605-978-9009

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

Provider Enumeration Date	:	08/28/2007
Last Update Date	:	03/06/2012

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