Provider Demographics
NPI:1184899833
Name:WILKINS CENTER FOR FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:WILKINS CENTER FOR FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:404-292-2900
Mailing Address - Street 1:5468 MEMORIAL DRIVE
Mailing Address - Street 2:STE A
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083
Mailing Address - Country:US
Mailing Address - Phone:404-292-2900
Mailing Address - Fax:404-292-3929
Practice Address - Street 1:5468 MEMORIAL DRIVE STE. A
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083
Practice Address - Country:US
Practice Address - Phone:404-292-2900
Practice Address - Fax:404-292-3929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA117921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00770316CMedicaid