Provider Demographics
NPI:1528024460
Name:WILKERSON, TRACY LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 KANAWHA BOULEVARD EAST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301
Mailing Address - Country:US
Mailing Address - Phone:304-345-0541
Mailing Address - Fax:304-345-8718
Practice Address - Street 1:1400 KANAWHA BOULEVARD EAST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-345-0541
Practice Address - Fax:304-345-8718
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4005111000Medicaid