Provider Demographics
NPI:1538234836
Name:WILSON, SCOTT R (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
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 1:1215 CURRENCY CT
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-2321
Mailing Address - Country:US
Mailing Address - Phone:815-562-2474
Mailing Address - Fax:
Practice Address - Street 1:1215 CURRENCY CT
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-2321
Practice Address - Country:US
Practice Address - Phone:815-562-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice