Healthcare Provider Details

I. General information

NPI: 1700104551
Provider Name (Legal Business Name): DAVID J WILSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6516 M D ANDERSON BLVD STE 2.059
HOUSTON TX
77030-3402
US

IV. Provider business mailing address

6516 M D ANDERSON BLVD STE 2.059
HOUSTON TX
77030-3402
US

V. Phone/Fax

Practice location:
  • Phone: 713-548-6599
  • Fax:
Mailing address:
  • Phone: 713-548-6599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberUTH-324-X
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: