Provider Demographics
NPI:1740303981
Name:WILSON, MARY BETH (DDS)
Entity type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1195 OLD HICKORY BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4239
Mailing Address - Country:US
Mailing Address - Phone:615-371-9500
Mailing Address - Fax:615-371-9845
Practice Address - Street 1:1195 OLD HICKORY BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-4239
Practice Address - Country:US
Practice Address - Phone:615-371-9500
Practice Address - Fax:615-371-9845
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
TNDS46931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice