Provider Demographics
NPI:1245344001
Name:WILKINSON, DALLAS CHARLES (OD)
Entity type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:CHARLES
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-2322
Mailing Address - Country:US
Mailing Address - Phone:605-745-3175
Mailing Address - Fax:
Practice Address - Street 1:200 S CHICAGO ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-2322
Practice Address - Country:US
Practice Address - Phone:605-745-3175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD575OtherDAKOTACARE
SD0007616OtherWELLMARK
SD9200700Medicaid
SDU83765Medicare UPIN
SD0007616OtherWELLMARK
SD410044835Medicare PIN
SD4145740001Medicare NSC