Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 9710 | TX |
NPI | 1124011002 |
---|---|
Provider Name | Dr. Thomas G. Wilson JR. |
First Address | Dallas, TX 75231-4100 |
Second Address | Dallas, TX 75231-4100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2005 |
Last Update Date | 08/07/2007 |