Provider Demographics
NPI:1316385883
Name:WILSON, STEPHEN RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RAY
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 1:8701 CAMINO MEDIA
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-1335
Mailing Address - Country:US
Mailing Address - Phone:661-861-8000
Mailing Address - Fax:
Practice Address - Street 1:8701 CAMINO MEDIA
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311
Practice Address - Country:US
Practice Address - Phone:661-861-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CA39352122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies