MEDICARE: DR. STEPHANIE ALEXIS WILSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	20305	TX

General Provider Information

NPI Number	:	1306062393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHANIE ALEXIS WILSON DDS

Provider Business Mailing Address
First Line	:	9119 HIGHWAY 6 STE 270
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4878
Country	:	US
Telephone Number	:	281-778-1990
Fax Number	:	281-778-1999

Provider Business Practice Location Address
First Line	:	9119 HIGHWAY 6 STE 270
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4878
Country	:	US
Telephone Number	:	281-778-1990
Fax Number	:	281-778-1999

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	01/03/2012

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