Provider Demographics
NPI:1407010523
Name:WILSON, ERIC S (DDS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:S
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 1:31654 RANCHO VIEJO RD
Mailing Address - Street 2:SUITE I-1
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-2773
Mailing Address - Country:US
Mailing Address - Phone:949-240-4337
Mailing Address - Fax:949-240-7337
Practice Address - Street 1:31654 RANCHO VIEJO RD
Practice Address - Street 2:SUITE I-1
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2773
Practice Address - Country:US
Practice Address - Phone:949-240-4337
Practice Address - Fax:949-240-7337
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA435721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice