Healthcare Provider Details

I. General information

NPI: 1427158070
Provider Name (Legal Business Name): THOMAS JAMES WICKLIFFE D.D.S.,M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 RIMROCK RD
BILLINGS MT
59102-0700
US

IV. Provider business mailing address

1690 RIMROCK RD
BILLINGS MT
59102-0700
US

V. Phone/Fax

Practice location:
  • Phone: 406-248-3303
  • Fax:
Mailing address:
  • Phone: 406-248-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1502
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: