Healthcare Provider Details

I. General information

NPI: 1760501001
Provider Name (Legal Business Name): TRACY L. WILKERSON, DDS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 KANAWHA BLVD E
CHARLESTON WV
25301-3002
US

IV. Provider business mailing address

1400 KANAWHA BLVD E
CHARLESTON WV
25301-3002
US

V. Phone/Fax

Practice location:
  • Phone: 304-345-0541
  • Fax: 304-345-8718
Mailing address:
  • Phone: 304-345-0541
  • Fax: 304-345-8718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3529
License Number StateWV

VIII. Authorized Official

Name: DR. TRACY LYNN WILKERSON
Title or Position: PEDIATRIC SPECIALIST
Credential: DDS
Phone: 304-345-0541