Healthcare Provider Details

I. General information

NPI: 1811049570
Provider Name (Legal Business Name): FRED H WILSON III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 SATTLER RD STE 4
CANYON LAKE TX
78132-2296
US

IV. Provider business mailing address

PO BOX 2225 1395 SATTLER RD #4
CANYON LAKE TX
78133-0009
US

V. Phone/Fax

Practice location:
  • Phone: 830-964-3161
  • Fax: 830-226-5019
Mailing address:
  • Phone: 830-964-3161
  • Fax: 830-226-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14592
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: