Provider Demographics
NPI:1700864345
Name:SMITH, WILSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:
Last Name:SMITH
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 1:3933 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:STE. E-200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8761
Mailing Address - Country:US
Mailing Address - Phone:512-343-1990
Mailing Address - Fax:
Practice Address - Street 1:3933 SPICEWOOD SPRINGS RD
Practice Address - Street 2:STE. E-200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8761
Practice Address - Country:US
Practice Address - Phone:512-343-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice