Healthcare Provider Details

I. General information

NPI: 1639127624
Provider Name (Legal Business Name): JOSEPH W. WILKES III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

147 MILK ST PROVIDER ENROLLMENT 9TH FLOOR
BOSTON MA
02109-4806
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1122
  • Fax:
Mailing address:
  • Phone: 617-559-8051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14190
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: