Provider Demographics
NPI:1346294063
Name:WILSON, BRUCE TAYLOR (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:TAYLOR
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1786
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-3786
Mailing Address - Country:US
Mailing Address - Phone:606-248-1808
Mailing Address - Fax:606-248-1803
Practice Address - Street 1:123 N 19TH STREET
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1786
Practice Address - Country:US
Practice Address - Phone:606-248-1808
Practice Address - Fax:606-248-1803
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY58111223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64058118Medicaid
KY60058112Medicaid
KY64058118Medicaid