Provider Demographics
NPI:1760633929
Name:WILSON, RICHARD ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALLEN
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 1:3828 W DAVIS ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1815
Mailing Address - Country:US
Mailing Address - Phone:936-756-9015
Mailing Address - Fax:
Practice Address - Street 1:3828 W DAVIS ST
Practice Address - Street 2:SUITE 310
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1815
Practice Address - Country:US
Practice Address - Phone:936-756-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX260651223G0001X
DCDEN10006351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1223G0001XOtherDENTIST-GENERAL PRACTICE
TX1223G0001XMedicaid