Healthcare Provider Details

I. General information

NPI: 1538181904
Provider Name (Legal Business Name): MARK W WILHELM DMD, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6861 UPPER AFTON RD STE 101
WOODBURY MN
55125-4418
US

IV. Provider business mailing address

6861 UPPER AFTON RD STE 101
WOODBURY MN
55125-4418
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-2427
  • Fax: 651-224-7414
Mailing address:
  • Phone: 651-227-2427
  • Fax: 651-224-7414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD10331
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: