Provider Demographics
NPI:1801071394
Name:JEFFREY A. WILSON, DDS, INC.
Entity type:Organization
Organization Name:JEFFREY A. WILSON, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-569-7563
Mailing Address - Street 1:101 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:OH
Mailing Address - Zip Code:43107-1175
Mailing Address - Country:US
Mailing Address - Phone:740-569-7563
Mailing Address - Fax:
Practice Address - Street 1:101 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:OH
Practice Address - Zip Code:43107-1175
Practice Address - Country:US
Practice Address - Phone:740-569-7563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300177051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty