Provider Demographics
NPI:1942224332
Name:WILSON, KELLEY STEWART (DMD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:STEWART
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:YVONNE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:19075 NW TANASBOURNE DR. #300
Mailing Address - Street 2:SUNSET DENTAL OFFICE
Mailing Address - City:HILLBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124
Mailing Address - Country:US
Mailing Address - Phone:503-531-1700
Mailing Address - Fax:503-531-1704
Practice Address - Street 1:5025 SE 28TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-4445
Practice Address - Country:US
Practice Address - Phone:503-238-4418
Practice Address - Fax:503-238-0360
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7960122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist