Provider Demographics
NPI:1861545055
Name:PILGRIM, TONY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:LEE
Last Name:PILGRIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6824 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-8773
Mailing Address - Country:US
Mailing Address - Phone:715-855-1105
Mailing Address - Fax:715-855-1163
Practice Address - Street 1:122 S. STATE ST.
Practice Address - Street 2:
Practice Address - City:FALL CREEK
Practice Address - State:WI
Practice Address - Zip Code:54742-0066
Practice Address - Country:US
Practice Address - Phone:715-877-2113
Practice Address - Fax:715-877-3495
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0031041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33458700Medicaid