Provider Demographics
NPI:1700100302
Name:STOVALL-WILSON, OLIVIA COURTNEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:COURTNEY
Last Name:STOVALL-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 1:1104 KENNESAW BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-6062
Mailing Address - Country:US
Mailing Address - Phone:615-973-4004
Mailing Address - Fax:
Practice Address - Street 1:1301 PEACHERS MILL RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-4610
Practice Address - Country:US
Practice Address - Phone:931-572-9152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN90391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice