Provider Demographics
NPI:1679920482
Name:WILSON, RYAN SCOTT (DMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:SCOTT
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3706 DAVIS STUART RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3706 DAVIS STUART RD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9463
Practice Address - Country:US
Practice Address - Phone:304-645-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-22
Last Update Date:2016-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4210122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist