Healthcare Provider Details

I. General information

NPI: 1093703928
Provider Name (Legal Business Name): STACY RONALD WILKERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 FLORENCE RD
SAVANNAH TN
38372-5205
US

IV. Provider business mailing address

1480 FLORENCE RD
SAVANNAH TN
38372-5205
US

V. Phone/Fax

Practice location:
  • Phone: 731-925-5396
  • Fax: 731-925-5349
Mailing address:
  • Phone: 731-925-5396
  • Fax: 731-925-5349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS7116
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: