MEDICARE: DR. DAVID G WILSON D.M.D., LLC

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	DS019605-L	PA

General Provider Information

NPI Number	:	1992708952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID G WILSON D.M.D., LLC

Provider Business Mailing Address
First Line	:	1372 N SUSQUEHANNA TRL
Second Line	:	SUITE 140
City	:	SELINSGROVE
State	:	PA
Zip	:	17870-8971
Country	:	US
Telephone Number	:	570-743-8119
Fax Number	:	570-743-2009

Provider Business Practice Location Address
First Line	:	1372 N SUSQUEHANNA TRL
Second Line	:	SUITE 140
City	:	SELINSGROVE
State	:	PA
Zip	:	17870-8971
Country	:	US
Telephone Number	:	570-743-8119
Fax Number	:	570-743-2009

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	12/23/2013

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