Provider Demographics
NPI:1023449220
Name:WILSON, SUSAN KAY (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 E LIVINGSTON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-2302
Mailing Address - Country:US
Mailing Address - Phone:614-235-5560
Mailing Address - Fax:614-235-1857
Practice Address - Street 1:3901 E LIVINGSTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2302
Practice Address - Country:US
Practice Address - Phone:614-235-5560
Practice Address - Fax:614-235-1857
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17498122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist