Provider Demographics
NPI:1467546713
Name:CARL CLINTON WILKINSON III, D.M.D., P.A.
Entity Type:Organization
Organization Name:CARL CLINTON WILKINSON III, D.M.D., P.A.
Other - Org Name:CLINT WILKINSON, D.M.D., P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:CLINTON
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-254-4111
Mailing Address - Street 1:1300 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5318
Mailing Address - Country:US
Mailing Address - Phone:321-254-4111
Mailing Address - Fax:321-254-0071
Practice Address - Street 1:1300 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5318
Practice Address - Country:US
Practice Address - Phone:321-254-4111
Practice Address - Fax:321-254-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL93571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty