Provider Demographics
NPI:1093703928
Name:WILKERSON, STACY RONALD (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:RONALD
Last Name:WILKERSON
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 1:1480 FLORENCE RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-5205
Mailing Address - Country:US
Mailing Address - Phone:731-925-5396
Mailing Address - Fax:731-925-5349
Practice Address - Street 1:1480 FLORENCE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-5205
Practice Address - Country:US
Practice Address - Phone:731-925-5396
Practice Address - Fax:731-925-5349
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS71161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice