Provider Demographics
NPI:1235286493
Name:WILSON, J CALVIN (DDS)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:CALVIN
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 1:317 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-2040
Mailing Address - Country:US
Mailing Address - Phone:618-662-6907
Mailing Address - Fax:618-662-7135
Practice Address - Street 1:317 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-2040
Practice Address - Country:US
Practice Address - Phone:618-662-6907
Practice Address - Fax:618-662-7135
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190230591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice