Healthcare Provider Details

I. General information

NPI: 1780098129
Provider Name (Legal Business Name): STEPHANIE M. WILSON D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8291 N BOOTH AVE
KANSAS CITY MO
64158-7202
US

IV. Provider business mailing address

9018 N SKYVIEW AVE
KANSAS CITY MO
64154-8501
US

V. Phone/Fax

Practice location:
  • Phone: 816-728-2979
  • Fax:
Mailing address:
  • Phone: 816-741-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number61506
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2014017372
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2014017372
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: