Basic Information
| Provider Information | |||||||||
| NPI: | 1861142275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINS | ||||||||
| FirstName: | DAYLENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | DAYLENE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 707 US HIGHWAY 24 N | ||||||||
| Address2: | |||||||||
| City: | BUENA VISTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812119863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193958610 | ||||||||
| FaxNumber: | 7193955745 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 US HIGHWAY 24 N | ||||||||
| Address2: | |||||||||
| City: | BUENA VISTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812119863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193958610 | ||||||||
| FaxNumber: | 7193955745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2022 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 905555 | CO | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 905555 | 01 | CO | LICENSURE | OTHER |