Provider Demographics
NPI:1154665800
Name:WILSON, KAREEN D (BS RDH)
Entity Type:Individual
Prefix:MRS
First Name:KAREEN
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:BS RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 FARMINGTON AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1544
Mailing Address - Country:US
Mailing Address - Phone:860-236-8000
Mailing Address - Fax:860-236-9205
Practice Address - Street 1:836 FARMINGTON AVE STE 215
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1544
Practice Address - Country:US
Practice Address - Phone:860-236-8000
Practice Address - Fax:860-236-9205
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006137124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist