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General NPI Number Information
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NPI Number | 1891771366
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Entity Type | Individual
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Provider Name | STEPHEN B WILSON DMD
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Gender | Male
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Dates
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Enumeration Date | 12/16/2005
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Last Update Date | 05/01/2012
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Provider Practice Location Address
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Address Line | 3515 DALLAS HWY SW STE B
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City | MARIETTA
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State | GA
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Zip | 30064-2095
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Country | US
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Telephone | 678-684-8157
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Fax |
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Provider Business Mailing Address
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Address Line | 41 MIDLAND LN
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City | DALLAS
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State | GA
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Zip | 30157-4133
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Country | US
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Telephone | 843-540-9790
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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 | 19026680
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License Number State | IL
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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 | 4249
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN013704
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License Number State | GA
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