Provider Demographics
NPI:1649330291
Name:WILSON, ROBERT G (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 COEUR CIRCLE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79922-2132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12801 EDGEMERE BLVD # B
Practice Address - Street 2:SUITE 112
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-9500
Practice Address - Country:US
Practice Address - Phone:915-493-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX244201223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200271909Medicaid