Provider Demographics
NPI:1881690816
Name:WILSON, CHARLES L (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
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 1:225 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5939
Mailing Address - Country:US
Mailing Address - Phone:573-334-7159
Mailing Address - Fax:
Practice Address - Street 1:225 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5939
Practice Address - Country:US
Practice Address - Phone:573-334-7159
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO116761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice