Provider Demographics
NPI:1124371489
Name:WILSON, GREGORY BLAKE (DDSMS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BLAKE
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDSMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 WYCLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-3512
Mailing Address - Country:US
Mailing Address - Phone:713-468-1513
Mailing Address - Fax:281-213-2756
Practice Address - Street 1:858 WYCLIFFE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-3512
Practice Address - Country:US
Practice Address - Phone:713-468-1513
Practice Address - Fax:281-213-2756
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17832122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist