Provider Demographics
NPI:1407996044
Name:WILSON, LOREN G (DDS)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:G
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 1:670 BIXLER RD
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-3786
Mailing Address - Country:US
Mailing Address - Phone:618-273-9684
Mailing Address - Fax:
Practice Address - Street 1:1030 4TH ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1702
Practice Address - Country:US
Practice Address - Phone:618-273-9361
Practice Address - Fax:618-273-7101
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice