Provider Demographics
NPI:1053584953
Name:WEST WILSON DENTAL GROUP LLC
Entity type:Organization
Organization Name:WEST WILSON DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOCTORA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:615-773-1150
Mailing Address - Street 1:66 E HILL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-8031
Mailing Address - Country:US
Mailing Address - Phone:615-773-1150
Mailing Address - Fax:615-773-1110
Practice Address - Street 1:66 E HILL DR
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-8031
Practice Address - Country:US
Practice Address - Phone:615-773-1150
Practice Address - Fax:615-773-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN72681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3226329Medicaid