Provider Demographics
NPI:1205085776
Name:WILSON, CONSTANCE LYNN (DMD)
Entity type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 JPM RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9340
Mailing Address - Country:US
Mailing Address - Phone:570-524-0600
Mailing Address - Fax:570-524-0296
Practice Address - Street 1:222 JPM RD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9340
Practice Address - Country:US
Practice Address - Phone:570-524-0600
Practice Address - Fax:570-524-0296
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037648122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist