Provider Demographics
NPI:1689836132
Name:DR. GREG L. WILSON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:DR. GREG L. WILSON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-645-7506
Mailing Address - Street 1:710 FEDERAL DR
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-1876
Mailing Address - Country:US
Mailing Address - Phone:731-645-7506
Mailing Address - Fax:731-645-5660
Practice Address - Street 1:710 FEDERAL DR
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-1876
Practice Address - Country:US
Practice Address - Phone:731-645-7506
Practice Address - Fax:731-645-5660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38321223G0001X
TN86951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN003729OtherDORAL DENTAL
792419OtherUNITED CONCORDIA
TN0106853OtherBC/BS OF TENNESSEE
TN0106853OtherBC/BS OF TENNESSEE