Provider Demographics
NPI:1932154648
Name:WILSON, SCOTT PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:PAUL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:IN
Mailing Address - Zip Code:47025-1549
Mailing Address - Country:US
Mailing Address - Phone:812-537-1390
Mailing Address - Fax:812-537-1390
Practice Address - Street 1:520 SHELDON ST
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:IN
Practice Address - Zip Code:47025-1549
Practice Address - Country:US
Practice Address - Phone:812-537-1390
Practice Address - Fax:812-537-1390
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009276122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist