Basic Information
| Provider Information | |||||||||
| NPI: | 1831591494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINSON | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | CLINTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1137 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329021137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219529696 | ||||||||
| FaxNumber: | 3219527937 | ||||||||
| Practice Location | |||||||||
| Address1: | 7227 N US HIGHWAY 1 | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329275020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218772740 | ||||||||
| FaxNumber: | 3218772793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2014 | ||||||||
| LastUpdateDate: | 10/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN 9357 | FL | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 019673000 | 05 | FL | MEDICAID |