Provider Demographics
NPI:1083748545
Name:WILSON, CRAIG STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:STEPHEN
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 1:105 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2301
Mailing Address - Country:US
Mailing Address - Phone:860-388-9774
Mailing Address - Fax:
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2301
Practice Address - Country:US
Practice Address - Phone:860-388-9774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0068361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice