Provider Demographics
NPI:1972638922
Name:WILSON, CHARLYN A (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLYN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7685 WOLF RIVER CIR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1749
Mailing Address - Country:US
Mailing Address - Phone:901-751-1100
Mailing Address - Fax:901-751-1164
Practice Address - Street 1:7685 WOLF RIVER CIR
Practice Address - Street 2:SUITE 102
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1749
Practice Address - Country:US
Practice Address - Phone:901-751-1100
Practice Address - Fax:901-751-1164
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS70791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4132991OtherBLUE CROSS BLUE SHIELD