Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 20179 | TX |
NPI | 1063574325 |
---|---|
Provider Name | Dr. Rebecca May Wilson |
First Address | San Antonio, TX 78258-2629 |
Second Address | San Antonio, TX 78258 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2006 |
Last Update Date | 28/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
111244304 | (05) | TX |