Provider Demographics
NPI:1831591494
Name:WILKINSON, CARL CLINTON III (DMD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:CLINTON
Last Name:WILKINSON
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:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:7227 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-5020
Practice Address - Country:US
Practice Address - Phone:321-877-2740
Practice Address - Fax:321-877-2793
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 9357122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019673000Medicaid