Provider Demographics
NPI:1114940715
Name:WILSON, CHESTER A (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 TUSCARAWAS ST E
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-2702
Mailing Address - Country:US
Mailing Address - Phone:330-453-7299
Mailing Address - Fax:330-453-7282
Practice Address - Street 1:2205 TUSCARAWAS ST E
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-2702
Practice Address - Country:US
Practice Address - Phone:330-453-7299
Practice Address - Fax:330-453-7282
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH195311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0880757Medicaid
OH2373Medicaid
OH34-1825962028Medicaid