Provider Demographics
NPI:1598861122
Name:WILGUS, MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WILGUS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 GRAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-2680
Mailing Address - Country:US
Mailing Address - Phone:406-652-5550
Mailing Address - Fax:406-652-0562
Practice Address - Street 1:2700 GRAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-2680
Practice Address - Country:US
Practice Address - Phone:406-652-5550
Practice Address - Fax:406-652-0562
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19101223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0115479Medicaid