Provider Demographics
NPI:1346294063
Name:WILSON, BRUCE TAYLOR (DMD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:TAYLOR
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1786
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-3786
Mailing Address - Country:US
Mailing Address - Phone:606-248-1808
Mailing Address - Fax:606-248-1803
Practice Address - Street 1:705 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1987
Practice Address - Country:US
Practice Address - Phone:606-248-1808
Practice Address - Fax:859-823-4137
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5811204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60058112Medicaid
KY64058118Medicaid
KY64058118Medicaid