Provider Demographics
NPI:1487949137
Name:WILKINSON ORTHODONTICS
Entity type:Organization
Organization Name:WILKINSON ORTHODONTICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:208-746-0479
Mailing Address - Street 1:3326 4TH ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5890
Mailing Address - Country:US
Mailing Address - Phone:208-746-0479
Mailing Address - Fax:208-798-3000
Practice Address - Street 1:3326 4TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5890
Practice Address - Country:US
Practice Address - Phone:208-746-0479
Practice Address - Fax:208-798-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806660900Medicaid
WA5045588Medicaid