Provider Demographics
NPI:1437508900
Name:WRIGHT, DALLAS GLEN (MD)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:GLEN
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 SKINNER DR
Mailing Address - Street 2:
Mailing Address - City:LORENA
Mailing Address - State:TX
Mailing Address - Zip Code:76655-3239
Mailing Address - Country:US
Mailing Address - Phone:804-358-7488
Mailing Address - Fax:
Practice Address - Street 1:6901 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-751-4242
Practice Address - Fax:254-751-4243
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS30922083P0011X
TXBP1OO57711207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX842047OtherMEDICARE