MEDICARE: RICHARD DREW DDS & J 'GUS' WILSON DDS PC

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	5039	OK

General Provider Information

NPI Number	:	1740335827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD DREW DDS & J 'GUS' WILSON DDS PC

Provider Business Mailing Address
First Line	:	1044 SW 44TH ST
Second Line	:	SUITE 510
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-3613
Country	:	US
Telephone Number	:	405-632-6601
Fax Number	:	405-632-6031

Provider Business Practice Location Address
First Line	:	1044 SW 44TH ST
Second Line	:	SUITE 510
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-3613
Country	:	US
Telephone Number	:	405-632-6601
Fax Number	:	405-632-6031

Authorized Official
Title or Position	:	DENTIST
Name	:	JEFF WILSON
Credential	:	DDS
Telephone Number	:	405-632-6601

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	08/22/2020

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