Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0004X | Dentist Anesthesiologist | 31333 | TX |
NPI | 1811363807 |
---|---|
Provider Name | Dr. Ryne Patrick Wilson |
First Address | Flower Mound, TX 75028-6030 |
Second Address | Flower Mound, TX 75028-6030 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2015 |
Last Update Date | 13/08/2015 |