Provider Demographics
NPI:1447386875
Name:WILSON, GREGORY L (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 FEDERAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375
Mailing Address - Country:US
Mailing Address - Phone:731-645-7506
Mailing Address - Fax:731-645-5660
Practice Address - Street 1:710 FEDERAL DRIVE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375
Practice Address - Country:US
Practice Address - Phone:731-645-7506
Practice Address - Fax:731-645-5660
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS38321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3226180Medicaid
TN0106853OtherBLUE CROSS BLUE SHIELD
792419OtherUNITED CONCORDIA
TN3226180Medicaid