MEDICARE: STEPHEN B WILSON DMD

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	122300000X	Dentist	19026680	IL
2	1223G0001X	General Practice Dentistry	4249	SC
3	1223G0001X	General Practice Dentistry	DN013704	GA

General Provider Information

NPI Number	:	1891771366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN B WILSON DMD

Provider Business Mailing Address
First Line	:	41 MIDLAND LN
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30157-4133
Country	:	US
Telephone Number	:	843-540-9790
Fax Number	:

Provider Business Practice Location Address
First Line	:	3515 DALLAS HWY SW STE B
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-2095
Country	:	US
Telephone Number	:	678-684-8157
Fax Number	:

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

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	05/01/2012

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