Provider Demographics
NPI:1568790186
Name:WILSON, THOMAS E (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG 128 CHAFFEE RD
Mailing Address - Street 2:US ARMY DENTAL ACTIVITY
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79916
Mailing Address - Country:US
Mailing Address - Phone:915-568-5001
Mailing Address - Fax:915-568-5174
Practice Address - Street 1:BLDG 128 CHAFFEE RD
Practice Address - Street 2:US ARMY DENTAL ACTIVIT
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79916
Practice Address - Country:US
Practice Address - Phone:915-568-5001
Practice Address - Fax:915-568-5174
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00249191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice