Provider Demographics
NPI:1154425262
Name:WILSON, ERIC STANLEY (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:STANLEY
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:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:COLE CAMP
Mailing Address - State:MO
Mailing Address - Zip Code:65325
Mailing Address - Country:US
Mailing Address - Phone:660-668-3322
Mailing Address - Fax:660-668-4419
Practice Address - Street 1:606 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLE CAMP
Practice Address - State:MO
Practice Address - Zip Code:65325
Practice Address - Country:US
Practice Address - Phone:660-668-3322
Practice Address - Fax:660-668-4419
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE015299122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist