Provider Demographics
NPI:1003091604
Name:YOUR HOUSTON DENTIST
Entity Type:Organization
Organization Name:YOUR HOUSTON DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:RIX
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:713-789-1200
Mailing Address - Street 1:2077 S GESSNER RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1147
Mailing Address - Country:US
Mailing Address - Phone:713-789-1200
Mailing Address - Fax:713-789-1219
Practice Address - Street 1:2077 S GESSNER RD
Practice Address - Street 2:SUITE 125
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-1147
Practice Address - Country:US
Practice Address - Phone:713-789-1200
Practice Address - Fax:713-789-1219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1053329185OtherNPI TYPE 1