Provider Demographics
NPI:1841404969
Name:WILSON, C THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:C
Middle Name:THOMAS
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 1:10589 S HIGHLAND RD
Mailing Address - Street 2:STE 4
Mailing Address - City:SISTER BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54234
Mailing Address - Country:US
Mailing Address - Phone:920-854-5200
Mailing Address - Fax:920-854-7601
Practice Address - Street 1:703 S BAY SHORE DR
Practice Address - Street 2:SUITE #4
Practice Address - City:SISTER BAY
Practice Address - State:WI
Practice Address - Zip Code:54234
Practice Address - Country:US
Practice Address - Phone:920-854-5200
Practice Address - Fax:920-854-7601
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1235G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33495100Medicaid