Provider Demographics
NPI:1922376706
Name:WILKE, KEVIN J (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:WILKE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BROADVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2805
Mailing Address - Country:US
Mailing Address - Phone:920-347-4560
Mailing Address - Fax:
Practice Address - Street 1:111 BROADVIEW DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2805
Practice Address - Country:US
Practice Address - Phone:920-347-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4522-0151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics