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General NPI Number Information
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NPI Number | 1962688275
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Entity Type | Individual
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Provider Name | MICHAEL THOMAS WILCKO D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/16/2008
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Last Update Date | 02/07/2025
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Provider Practice Location Address
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Address Line | 90 E MAIN ST
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City | NORTH EAST
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State | PA
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Zip | 16428-1319
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Country | US
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Telephone | 814-725-4700
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Fax |
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Provider Business Mailing Address
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Address Line | 90 E MAIN ST
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City | NORTH EAST
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State | PA
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Zip | 16428-1319
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Country | US
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Telephone | 814-725-4700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DS018955L
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License Number State | PA
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