Provider Demographics
NPI:1013069111
Name:WILBERT, MITCHELL WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:WILLIAM
Last Name:WILBERT
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:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:WESTERNVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13486-0025
Mailing Address - Country:US
Mailing Address - Phone:315-827-4534
Mailing Address - Fax:
Practice Address - Street 1:710 BLACK RIVER BLVD N
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-4328
Practice Address - Country:US
Practice Address - Phone:315-339-5364
Practice Address - Fax:315-339-5365
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0392651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice