Provider Demographics
NPI:1427220979
Name:WILKS, TRUITT PALMER JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRUITT
Middle Name:PALMER
Last Name:WILKS
Suffix:JR
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: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
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2304-861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice