Provider Demographics
NPI:1275503252
Name:WILSON, EMMETT E (DDS)
Entity Type:Individual
Prefix:
First Name:EMMETT
Middle Name:E
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 1:1453 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-2110
Mailing Address - Country:US
Mailing Address - Phone:860-727-8146
Mailing Address - Fax:860-241-0564
Practice Address - Street 1:1453 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-2110
Practice Address - Country:US
Practice Address - Phone:860-727-8146
Practice Address - Fax:860-241-0564
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT54981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice