Healthcare Provider Details

I. General information

NPI: 1992417117
Provider Name (Legal Business Name): HOUSTON WISDOM TEETH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12004 SHADOW CREEK PKWY SUITE #122-A,
PEARLAND TX
77584
US

IV. Provider business mailing address

5513 W 11000 N STE 226
HIGHLAND UT
84003-8012
US

V. Phone/Fax

Practice location:
  • Phone: 713-424-2824
  • Fax:
Mailing address:
  • Phone: 801-899-5512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN HILTON
Title or Position: MANAGING MEMBER
Credential: DDS
Phone: 208-484-2376