Healthcare Provider Details

I. General information

NPI: 1801907712
Provider Name (Legal Business Name): CRESCENTHIA ANN WILKEN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 40TH AVE NE
COLUMBIA HEIGHTS MN
55421
US

IV. Provider business mailing address

700 40TH AVE NE
COLUMBIA HEIGHTS MN
55421
US

V. Phone/Fax

Practice location:
  • Phone: 763-788-1625
  • Fax:
Mailing address:
  • Phone: 763-788-1625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8733
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: