Provider Demographics
NPI:1649356726
Name:WILSON, LEE EUGENE (DDS)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:EUGENE
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 1:6621 KIRBY CENTER CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-4313
Mailing Address - Country:US
Mailing Address - Phone:901-363-3014
Mailing Address - Fax:901-362-6103
Practice Address - Street 1:6621 KIRBY CENTER CV
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-4313
Practice Address - Country:US
Practice Address - Phone:901-363-3014
Practice Address - Fax:901-362-6103
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS37851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice