Provider Demographics
NPI:1417152786
Name:CRAIG S. WILSON, D.D.S., LLC
Entity Type:Organization
Organization Name:CRAIG S. WILSON, D.D.S., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-388-9774
Mailing Address - Street 1:105 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2301
Mailing Address - Country:US
Mailing Address - Phone:860-388-9774
Mailing Address - Fax:
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2301
Practice Address - Country:US
Practice Address - Phone:860-388-9774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0068361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty