Provider Demographics
NPI:1861573594
Name:WILSON, ROGER DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DALE
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 1:8345 WALNUT HILL LN STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4246
Mailing Address - Country:US
Mailing Address - Phone:214-363-4021
Mailing Address - Fax:214-360-9435
Practice Address - Street 1:8345 WALNUT HILL LN STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4246
Practice Address - Country:US
Practice Address - Phone:214-363-4021
Practice Address - Fax:214-360-9435
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX162331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice