Provider Demographics
NPI:1124011002
Name:WILSON, THOMAS G JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5465 BLAIR RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4100
Mailing Address - Country:US
Mailing Address - Phone:214-691-2404
Mailing Address - Fax:214-691-2228
Practice Address - Street 1:5465 BLAIR RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4100
Practice Address - Country:US
Practice Address - Phone:214-691-2404
Practice Address - Fax:214-691-2228
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX97101223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics