Provider Demographics
NPI:1053474338
Name:WILKERSON, HAROLD T (DMD)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:T
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-2325
Mailing Address - Country:US
Mailing Address - Phone:270-465-6204
Mailing Address - Fax:270-469-9424
Practice Address - Street 1:227 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2325
Practice Address - Country:US
Practice Address - Phone:270-465-6204
Practice Address - Fax:270-469-9424
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60037926Medicaid
KY621709924OtherTIN