Provider Demographics
NPI:1528084829
Name:BAPTIST-WILSON, BETTYE RUTH (DDS)
Entity type:Individual
Prefix:DR
First Name:BETTYE
Middle Name:RUTH
Last Name:BAPTIST-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:PO BOX 1168
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0012
Mailing Address - Country:US
Mailing Address - Phone:662-349-1141
Mailing Address - Fax:662-349-6227
Practice Address - Street 1:1305 CHURCH RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9711
Practice Address - Country:US
Practice Address - Phone:662-349-1141
Practice Address - Fax:662-349-6227
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1864-80122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist