Provider Demographics
NPI:1881817625
Name:WILSON, THOMAS GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GREGORY
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SOUTH PORTER STREET
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-1734
Mailing Address - Country:US
Mailing Address - Phone:731-658-5313
Mailing Address - Fax:731-658-5313
Practice Address - Street 1:105 SOUTH PORTER STREET
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1734
Practice Address - Country:US
Practice Address - Phone:731-658-5313
Practice Address - Fax:731-658-5313
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS40081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice