Provider Demographics
NPI:1710018494
Name:WILSON, STEPHEN JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JAMES
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 1:729 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:GARBERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95542-3201
Mailing Address - Country:US
Mailing Address - Phone:707-923-2753
Mailing Address - Fax:707-923-4203
Practice Address - Street 1:729 CEDAR ST
Practice Address - Street 2:
Practice Address - City:GARBERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95542-3201
Practice Address - Country:US
Practice Address - Phone:707-923-2753
Practice Address - Fax:707-923-4203
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD204891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice