Healthcare Provider Details

I. General information

NPI: 1710018494
Provider Name (Legal Business Name): STEPHEN JAMES WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 CEDAR ST
GARBERVILLE CA
95542-3201
US

IV. Provider business mailing address

729 CEDAR ST
GARBERVILLE CA
95542-3201
US

V. Phone/Fax

Practice location:
  • Phone: 707-923-2753
  • Fax: 707-923-4203
Mailing address:
  • Phone: 707-923-2753
  • Fax: 707-923-4203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD20489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: