Provider Demographics
NPI:1649298944
Name:WILSON, THOMAS BENEDICT I (DDS,MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BENEDICT
Last Name:WILSON
Suffix:I
Gender:M
Credentials:DDS,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CT
Mailing Address - Zip Code:06878-2113
Mailing Address - Country:US
Mailing Address - Phone:203-637-4045
Mailing Address - Fax:
Practice Address - Street 1:23 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5620
Practice Address - Country:US
Practice Address - Phone:203-661-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049719-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery