Provider Demographics
NPI:1689676652
Name:WILSON, GLENN M (DMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 DANBURY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-3427
Mailing Address - Country:US
Mailing Address - Phone:860-354-3737
Mailing Address - Fax:860-350-2927
Practice Address - Street 1:146 DANBURY RD
Practice Address - Street 2:SUITE C
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-3427
Practice Address - Country:US
Practice Address - Phone:860-354-3737
Practice Address - Fax:860-350-2927
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT75241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice