Provider Demographics
NPI:1902812852
Name:WILSON, ROBERT LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LAWRENCE
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 1:708 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-3752
Mailing Address - Country:US
Mailing Address - Phone:501-362-5897
Mailing Address - Fax:501-362-2454
Practice Address - Street 1:708 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-3752
Practice Address - Country:US
Practice Address - Phone:501-362-5897
Practice Address - Fax:501-362-2454
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist