MEDICARE: JACK W. WILSON 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	5303	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	450463188002	OTHER	OK	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1598774465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK W. WILSON DDS

Provider Business Mailing Address
First Line	:	1201 MENA ST
Second Line	:
City	:	MENA
State	:	AR
Zip	:	71953-4280
Country	:	US
Telephone Number	:	479-394-2332
Fax Number	:	479-437-3708

Provider Business Practice Location Address
First Line	:	534 LUZERNE ST
Second Line	:
City	:	MOUNT IDA
State	:	AR
Zip	:	71957-9449
Country	:	US
Telephone Number	:	870-867-4244
Fax Number	:	870-867-4254

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

Provider Enumeration Date	:	08/07/2006
Last Update Date	:	04/14/2008

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