Provider Demographics
NPI:1538181904
Name:WILHELM, MARK W (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:WILHELM
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6861 UPPER AFTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4418
Mailing Address - Country:US
Mailing Address - Phone:651-227-2427
Mailing Address - Fax:651-224-7414
Practice Address - Street 1:6861 UPPER AFTON RD STE 101
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4418
Practice Address - Country:US
Practice Address - Phone:651-227-2427
Practice Address - Fax:651-224-7414
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND103311223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN252522400OtherMEDICAL ASSISTANCE