Provider Demographics
NPI:1326587767
Name:RICHARD A. WILSON, DDS, PA
Entity Type:Organization
Organization Name:RICHARD A. WILSON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:936-756-9015
Mailing Address - Street 1:3828 W DAVIS ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1815
Mailing Address - Country:US
Mailing Address - Phone:936-756-9015
Mailing Address - Fax:936-756-7098
Practice Address - Street 1:3828 W DAVIS ST
Practice Address - Street 2:SUITE 310
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1815
Practice Address - Country:US
Practice Address - Phone:936-756-9015
Practice Address - Fax:936-756-7098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26065305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service