Provider Demographics
NPI:1750868436
Name:WILSON, JOHN RILEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RILEY
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 1:2133 PEPPERRELL ST
Mailing Address - Street 2:
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2133 PEPPERRELL ST
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-5313
Practice Address - Country:US
Practice Address - Phone:210-292-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000107601223G0001X, 1223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics