Provider Demographics
NPI:1962561290
Name:WILSON, BRUCE T (DDS)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:T
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:PO BOX 1345
Mailing Address - Street 2:322 HWY 18
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-1345
Mailing Address - Country:US
Mailing Address - Phone:870-561-4400
Mailing Address - Fax:870-561-4037
Practice Address - Street 1:322 HWY 18
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442
Practice Address - Country:US
Practice Address - Phone:870-561-4400
Practice Address - Fax:870-561-4037
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR31791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice