Provider Demographics
NPI:1962773002
Name:WILSON, TIMOTHY LEA (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LEA
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 EPIC WAY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-8142
Mailing Address - Country:US
Mailing Address - Phone:614-886-3543
Mailing Address - Fax:
Practice Address - Street 1:2655 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-2804
Practice Address - Country:US
Practice Address - Phone:614-875-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0232821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice