Provider Demographics
NPI:1750470829
Name:WILSON, CHRISTOPHER MCLEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:MCLEAN
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:P.O. BOX 416
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060
Mailing Address - Country:US
Mailing Address - Phone:802-728-3343
Mailing Address - Fax:802-276-3538
Practice Address - Street 1:55 CENTRAL STREET
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060
Practice Address - Country:US
Practice Address - Phone:802-728-3343
Practice Address - Fax:802-276-3538
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT16-00011841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1003924Medicaid