MEDICARE: DEWITT C WILKERSON DMD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1407347727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEWITT C WILKERSON DMD PA

Provider Business Mailing Address
First Line	:	390 4TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33701-2802
Country	:	US
Telephone Number	:	727-282-1980
Fax Number	:

Provider Business Practice Location Address
First Line	:	390 4TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33701-2802
Country	:	US
Telephone Number	:	727-282-1980
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DE WITT WILKERSON
Credential	:
Telephone Number	:	727-282-1980

Provider Enumeration Date	:	05/22/2018
Last Update Date	:	05/22/2018

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