Healthcare Provider Details

I. General information

NPI: 1821042797
Provider Name (Legal Business Name): STEPHEN WILSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 BUTTERFLY GARDENS DR
COLUMBUS OH
43215-7508
US

IV. Provider business mailing address

700 CHILDRENS DR
COLUMBUS OH
43205-2664
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-5650
  • Fax:
Mailing address:
  • Phone: 614-722-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.018004
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30.018004
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: