Provider Demographics
NPI:1770610826
Name:WILSON, BARRY JAY (DMD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:JAY
Last Name:WILSON
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:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029-0304
Mailing Address - Country:US
Mailing Address - Phone:270-395-7116
Mailing Address - Fax:270-395-7439
Practice Address - Street 1:404 FIFTH AVENUE
Practice Address - Street 2:
Practice Address - City:CALVERT CITY
Practice Address - State:KY
Practice Address - Zip Code:42029
Practice Address - Country:US
Practice Address - Phone:270-395-7116
Practice Address - Fax:270-395-7439
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY70391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice