Provider Demographics
NPI:1285014019
Name:WILSON, ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
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 1:694 GAP OF RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RURAL RETREAT
Mailing Address - State:VA
Mailing Address - Zip Code:24368-2732
Mailing Address - Country:US
Mailing Address - Phone:276-686-5923
Mailing Address - Fax:
Practice Address - Street 1:195 E SPRING ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2659
Practice Address - Country:US
Practice Address - Phone:276-228-8571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-07
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014148021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice