Provider Demographics
NPI:1891771366
Name:WILSON, STEPHEN B (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:B
Last Name:WILSON
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 1:41 MIDLAND LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-4133
Mailing Address - Country:US
Mailing Address - Phone:843-540-9790
Mailing Address - Fax:
Practice Address - Street 1:3515 DALLAS HWY SW STE B
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2095
Practice Address - Country:US
Practice Address - Phone:678-684-8157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19026680122300000X
SC42491223G0001X
GADN0137041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OTHMedicare UPIN