Provider Demographics
NPI:1730700477
Name:WILSON, LAUREN BRITTANY (DMD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:BRITTANY
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 OLD COLLINSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2511
Mailing Address - Country:US
Mailing Address - Phone:618-236-0501
Mailing Address - Fax:618-222-2997
Practice Address - Street 1:4121 OLD COLLINSVILLE RD
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2511
Practice Address - Country:US
Practice Address - Phone:618-236-0501
Practice Address - Fax:618-222-2997
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0325461223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist