Provider Demographics
NPI:1407946817
Name:WILKS, THOMAS R (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:WILKS
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 1:1263 ELK ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:PA
Mailing Address - Zip Code:16323-1312
Mailing Address - Country:US
Mailing Address - Phone:814-437-5622
Mailing Address - Fax:814-437-3677
Practice Address - Street 1:1263 ELK ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:PA
Practice Address - Zip Code:16323-1312
Practice Address - Country:US
Practice Address - Phone:814-437-5622
Practice Address - Fax:814-437-3677
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-016988-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT 28354Medicare UPIN