MEDICARE: DR. SCOTT WILSON DDS PLLC 4

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	122300000X	Dentist
2	1223E0200X	Endodontics
3	1223P0700X	Prosthodontics
4	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1649039793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. SCOTT WILSON DDS PLLC 4

Provider Business Mailing Address
First Line	:	1212 S MARYLAND PKWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1728
Country	:	US
Telephone Number	:	725-291-5588
Fax Number	:

Provider Business Practice Location Address
First Line	:	1212 S MARYLAND PKWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1728
Country	:	US
Telephone Number	:	725-291-5588
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SCOTT WILSON
Credential	:
Telephone Number	:	725-291-5588

Provider Enumeration Date	:	03/18/2024
Last Update Date	:	03/18/2024

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