Provider Demographics
NPI:1639127624
Name:WILKES, JOSEPH W III (DMD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:W
Last Name:WILKES
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8051
Mailing Address - Fax:
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA141901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ04037OtherBLUE CROSS
MA0014822OtherNEIGHBORHOOD HEALTH PLAN
MA053896OtherTUFTS HEALTH PLAN
MAPH126OtherHARVARD PILGRIM
MAX04592OtherBCBS DENTAL
MA6245667-002OtherCIGNA
MAPH126OtherHARVARD PILGRIM
MAJ04037Medicare ID - Type Unspecified