Provider Demographics
NPI:1629399522
Name:WILSON, CHARLES BRENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRENT
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:PO BOX 474
Mailing Address - Street 2:7689 US HWY 61
Mailing Address - City:SAINT FRANCISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70775-0474
Mailing Address - Country:US
Mailing Address - Phone:225-635-6554
Mailing Address - Fax:225-635-6239
Practice Address - Street 1:7689 US HWY 61
Practice Address - Street 2:
Practice Address - City:SAINT FRANCISVILLE
Practice Address - State:LA
Practice Address - Zip Code:70775-0820
Practice Address - Country:US
Practice Address - Phone:225-635-6554
Practice Address - Fax:225-635-6239
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice