Provider Demographics
NPI:1811049570
Name:WILSON, FRED H III (DDS)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:H
Last Name:WILSON
Suffix:III
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:PO BOX 2225
Mailing Address - Street 2:1395 SATTLER RD #4
Mailing Address - City:CANYON LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:78133-0009
Mailing Address - Country:US
Mailing Address - Phone:830-964-3161
Mailing Address - Fax:830-226-5019
Practice Address - Street 1:1395 SATTLER RD STE 4
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:TX
Practice Address - Zip Code:78132-2296
Practice Address - Country:US
Practice Address - Phone:830-964-3161
Practice Address - Fax:830-226-5019
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX145921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice