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General NPI Number Information
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NPI Number | 1427548833
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Entity Type | Individual
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Provider Name | KEVIN WILSON DDS
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Gender | Male
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Dates
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Enumeration Date | 05/11/2018
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Last Update Date | 10/22/2025
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Provider Practice Location Address
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Address Line | 9521 S WESTERN AVE
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City | CHICAGO
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State | IL
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Zip | 60643-1013
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Country | US
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Telephone | 773-344-9120
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Fax |
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Provider Business Mailing Address
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Address Line | 1931 S CLARK ST UNIT C
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City | CHICAGO
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State | IL
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Zip | 60616-1984
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Country | US
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Telephone | 202-486-3697
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30.025427
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019032065
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License Number State | IL
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