Provider Demographics
NPI:1306018619
Name:T. PALMER WILKS, JR., D.M.D., P.A.
Entity Type:Organization
Organization Name:T. PALMER WILKS, JR., D.M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:T. PALMER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-856-4110
Mailing Address - Street 1:PO BOX 859
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-0859
Mailing Address - Country:US
Mailing Address - Phone:601-856-4110
Mailing Address - Fax:601-856-8109
Practice Address - Street 1:213 HOY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8709
Practice Address - Country:US
Practice Address - Phone:601-856-4110
Practice Address - Fax:601-856-8109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2304-86261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental