Provider Demographics
NPI:1396880902
Name:WILSON III, JACK T (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:T
Last Name:WILSON III
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 1:12010 SHELBYVILLE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1054
Mailing Address - Country:US
Mailing Address - Phone:502-583-4771
Mailing Address - Fax:502-584-9922
Practice Address - Street 1:12010 SHELBYVILLE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1054
Practice Address - Country:US
Practice Address - Phone:502-583-4771
Practice Address - Fax:502-584-9922
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5247OtherDENTIST - GENERAL PRACTIT