Provider Demographics
NPI:1962723502
Name:CHARLES BRENT WILSON DDS LLC
Entity type:Organization
Organization Name:CHARLES BRENT WILSON DDS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-454-9680
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:7689 US HWY 61
Mailing Address - City:SAINT FRANCISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70775-0474
Mailing Address - Country:US
Mailing Address - Phone:225-635-6554
Mailing Address - Fax:225-635-6239
Practice Address - Street 1:7689 US HWY 61
Practice Address - Street 2:
Practice Address - City:SAINT FRANCISVILLE
Practice Address - State:LA
Practice Address - Zip Code:70775-0820
Practice Address - Country:US
Practice Address - Phone:225-635-6554
Practice Address - Fax:225-635-6239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty