Provider Demographics
NPI:1811363807
Name:WILSON, RYNE PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYNE
Middle Name:PATRICK
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 1:8603 FOREST HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-4024
Mailing Address - Country:US
Mailing Address - Phone:432-352-1305
Mailing Address - Fax:
Practice Address - Street 1:8603 FOREST HILLS BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-4024
Practice Address - Country:US
Practice Address - Phone:432-352-1305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX313331223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350348402Medicaid