Healthcare Provider Details

I. General information

NPI: 1902812852
Provider Name (Legal Business Name): ROBERT LAWRENCE WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
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: 501-362-2454
Mailing address:
  • Phone: 501-362-5897
  • Fax: 501-362-2454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: