Provider Demographics
NPI:1821122102
Name:WILSON, JACK A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
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 1:2200 INTERSTATE 20 W STE 200
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-1649
Mailing Address - Country:US
Mailing Address - Phone:817-467-0727
Mailing Address - Fax:817-465-2372
Practice Address - Street 1:2200 INTERSTATE 20 W STE 200
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1649
Practice Address - Country:US
Practice Address - Phone:817-467-0727
Practice Address - Fax:817-465-2372
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX92701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice