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NPI Code Detail

MEDICARE: DR. GREG L. WILSON FAMILY DENTISTRY

MEDICARE: DR. GREG L. WILSON FAMILY DENTISTRY
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
11223G0001XGeneral Practice Dentistry8695TN
21223G0001XGeneral Practice Dentistry3832TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1003729OTHERTNDORAL DENTAL
2792419OTHERUNITED CONCORDIA
30106853OTHERTNBC/BS OF TENNESSEE

General Provider Information

NPI Number : 1689836132
Entity Type Code : Organization
Provider Name (Legal Business Name) : DR. GREG L. WILSON FAMILY DENTISTRY
Provider Business Mailing Address
First Line : 710 FEDERAL DR
Second Line :
City : SELMER
State : TN
Zip : 38375-1876
Country : US
Telephone Number : 731-645-7506
Fax Number : 731-645-5660
Provider Business Practice Location Address
First Line : 710 FEDERAL DR
Second Line :
City : SELMER
State : TN
Zip : 38375-1876
Country : US
Telephone Number : 731-645-7506
Fax Number : 731-645-5660
Authorized Official
Title or Position : INSURANCE COORDINATOR
Name : CHRISTINA L KING
Credential :
Telephone Number : 731-645-7506
Provider Enumeration Date : 06/26/2008
Last Update Date : 06/26/2008

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