Provider Demographics
NPI:1396046264
Name:GIN, WILSON (LAC, D AC)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:GIN
Suffix:
Gender:M
Credentials:LAC, D AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9603 WHITE ROCK TRL
Mailing Address - Street 2:SUITE 326
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-5012
Mailing Address - Country:US
Mailing Address - Phone:214-669-9298
Mailing Address - Fax:
Practice Address - Street 1:2250 HIGHLAND VILLAGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:HIGHLAND VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75077-7146
Practice Address - Country:US
Practice Address - Phone:972-317-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00902171100000X
RIDA00368171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist