Individual
MISS RAVEN N. WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.D.S.
Contact information
Practice address
6222 HULEN BEND BLVD, FORT WORTH, TX 76132-2803
(817) 546-3335
Mailing address
6222 HULEN BEND BLVD, FORT WORTH, TX 76132-2803
(817) 546-3335
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
31866
TX
1223P0221X
Pediatric Dentistry
Primary
31866
TX
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
07/07/2015
Last updated
08/06/2020
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