Healthcare Provider Details

I. General information

NPI: 1396958773
Provider Name (Legal Business Name): ROBERT L. WILSON DDS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 W QUITMAN ST
HEBER SPRINGS AR
72543-3752
US

IV. Provider business mailing address

708 W QUITMAN ST
HEBER SPRINGS AR
72543-3752
US

V. Phone/Fax

Practice location:
  • Phone: 501-362-5897
  • Fax:
Mailing address:
  • Phone: 501-362-5897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3165
License Number StateAR

VIII. Authorized Official

Name: DR. ROBERT LAWRENCE WILSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 501-362-5897