Provider Demographics
NPI:1053329185
Name:WILSON, BRADLEY RIX (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:RIX
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27234 STARK LN
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77385-8071
Mailing Address - Country:US
Mailing Address - Phone:329-981-9418
Mailing Address - Fax:
Practice Address - Street 1:2619 S ELM PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7878
Practice Address - Country:US
Practice Address - Phone:918-872-0218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82421223G0001X
OK31381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice