Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 5811 | KY |
N | 204E00000X | Oral & Maxillofacial Surgeon | 5811 | KY |
NPI | 1346294063 |
---|---|
Provider Name | Dr. Bruce Taylor Wilson |
First Address | Middlesboro, KY 40965-3786 |
Second Address | Middlesboro, KY 40965-1786 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
60058112 | (05) | KY |
64058118 | (05) | KY |