Provider Demographics
NPI:1427548833
Name:WILSON, KEVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
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 1:2034 STURBRIDGE DR APT B2
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-4424
Mailing Address - Country:US
Mailing Address - Phone:202-486-3697
Mailing Address - Fax:
Practice Address - Street 1:2034 STURBRIDGE DR APT B2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-4424
Practice Address - Country:US
Practice Address - Phone:202-486-3697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025427122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist