Provider Demographics
NPI:1396031654
Name:WILSON, STEPHANIE IVY
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:IVY
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3091 COLLEGE PARK DR
Mailing Address - Street 2:SUITE #125
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77384-8023
Mailing Address - Country:US
Mailing Address - Phone:832-326-3286
Mailing Address - Fax:
Practice Address - Street 1:3091 COLLEGE PARK DR
Practice Address - Street 2:SUITE #125
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-8023
Practice Address - Country:US
Practice Address - Phone:832-326-3286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist