Provider Demographics
NPI:1629574595
Name:WILKES, STEFAN JAMES (DMD)
Entity Type:Individual
Prefix:MR
First Name:STEFAN
Middle Name:JAMES
Last Name:WILKES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 PROVIDENCE LN
Mailing Address - Street 2:
Mailing Address - City:MC CORMICK
Mailing Address - State:SC
Mailing Address - Zip Code:29835-4230
Mailing Address - Country:US
Mailing Address - Phone:864-293-9454
Mailing Address - Fax:
Practice Address - Street 1:150 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-3364
Practice Address - Country:US
Practice Address - Phone:864-583-3717
Practice Address - Fax:864-573-6067
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-01
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC95731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice