Provider Demographics
NPI:1063478618
Name:WILKINSON, MITCHELL R (DDS)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:R
Last Name:WILKINSON
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 187
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:575-759-3291
Mailing Address - Fax:575-759-3532
Practice Address - Street 1:PO BOX 187
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0187
Practice Address - Country:US
Practice Address - Phone:575-759-3291
Practice Address - Fax:575-759-3532
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX158811223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0900169-03Medicaid
TX89D015OtherBLUE SHIELD
TXP00214022OtherRR/MEDICARE
TX0900169-04Medicaid
TX0900169-03Medicaid
TXU20456Medicare UPIN