MEDICARE: WILKES DENTAL CONSORTIUM INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	07095	OTHER	NC	INSURANCE

General Provider Information

NPI Number	:	1184728339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILKES DENTAL CONSORTIUM INC

Provider Business Mailing Address
First Line	:	1915 WEST PARK DR
Second Line	:	SUITE 104
City	:	N WILKESBORO
State	:	NC
Zip	:	28659-3777
Country	:	US
Telephone Number	:	336-903-7302
Fax Number	:	336-903-0464

Provider Business Practice Location Address
First Line	:	1915 WEST PARK DR
Second Line	:	SUITE 104
City	:	N WILKESBORO
State	:	NC
Zip	:	28659-3777
Country	:	US
Telephone Number	:	336-903-7302
Fax Number	:	336-903-0464

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. JERALD H. ATKINS
Credential	:
Telephone Number	:	336-903-7302

Provider Enumeration Date	:	09/09/2006
Last Update Date	:	10/26/2007

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