Provider Demographics
NPI:1760501001
Name:TRACY L. WILKERSON, DDS, PLLC
Entity Type:Organization
Organization Name:TRACY L. WILKERSON, DDS, PLLC
Other - Org Name:CHILDREN'S DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC SPECIALIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-345-0541
Mailing Address - Street 1:1400 KANAWHA BLVD E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-3002
Mailing Address - Country:US
Mailing Address - Phone:304-345-0541
Mailing Address - Fax:304-345-8718
Practice Address - Street 1:1400 KANAWHA BLVD E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3002
Practice Address - Country:US
Practice Address - Phone:304-345-0541
Practice Address - Fax:304-345-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1528024460OtherINDIVIDUAL NPI
WV4005111000Medicaid
WV3810005586Medicaid