Provider Demographics
NPI:1750525630
Name:STILSON, JAY (DMD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:STILSON
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:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:BICKNELL
Mailing Address - State:UT
Mailing Address - Zip Code:84715-0303
Mailing Address - Country:US
Mailing Address - Phone:435-425-3744
Mailing Address - Fax:435-425-3785
Practice Address - Street 1:128 S 300 W
Practice Address - Street 2:
Practice Address - City:BICKNELL
Practice Address - State:UT
Practice Address - Zip Code:84715-0303
Practice Address - Country:US
Practice Address - Phone:435-425-3744
Practice Address - Fax:435-425-3785
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6714249-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist