Healthcare Provider Details

I. General information

NPI: 1619921533
Provider Name (Legal Business Name): TIMOTHY J. WILKINS D.D.S.,M.S.,P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 HOLLAND AVE
PORT HURON MI
48060-1520
US

IV. Provider business mailing address

1950 HOLLAND AVE
PORT HURON MI
48060-1520
US

V. Phone/Fax

Practice location:
  • Phone: 801-985-9567
  • Fax: 810-985-4203
Mailing address:
  • Phone: 810-985-9567
  • Fax: 810-985-4203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901010505
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: