Provider Demographics
NPI:1992119598
Name:WILKS, KONITA LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:KONITA
Middle Name:LEE
Last Name:WILKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6021 KENWICK CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1036
Mailing Address - Country:US
Mailing Address - Phone:714-642-5200
Mailing Address - Fax:
Practice Address - Street 1:10602 CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-3146
Practice Address - Country:US
Practice Address - Phone:714-537-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2015-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA634331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry