Provider Demographics
NPI:1811377625
Name:WILSON, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3594 COVINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-3926
Mailing Address - Country:US
Mailing Address - Phone:901-377-6800
Mailing Address - Fax:
Practice Address - Street 1:3594 COVINGTON PIKE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-3926
Practice Address - Country:US
Practice Address - Phone:901-377-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-06
Last Update Date:2015-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10057122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist