Provider Demographics
NPI:1326196072
Name:WILSON, STEVEN R (DDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:R
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 1:8600 E VIA DE VENTURA STE 201
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-3325
Mailing Address - Country:US
Mailing Address - Phone:480-948-6549
Mailing Address - Fax:480-948-0792
Practice Address - Street 1:8600 E VIA DE VENTURA STE 201
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-3325
Practice Address - Country:US
Practice Address - Phone:480-948-6549
Practice Address - Fax:480-948-0792
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1801844121OtherTYPE II - NPI NUMBER