Organization
BRUCE T. WILSON,D.M.D., PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRUCE TAYLOR WILSON DMD (PRESIDENT)
(606) 248-1808
Entity
Organization
Contact information
Practice address
123 N 19TH ST, MIDDLESBORO, KY 40965-2865
(606) 248-1808
(606) 248-1803
Mailing address
123 N 19TH ST, PO BOX 1786, MIDDLESBORO, KY 40965-2865
(606) 248-1808
(606) 248-1803
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
5811
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
64058118
—
KY
Enumeration date
10/24/2007
Last updated
10/24/2007
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