Provider Demographics
NPI:1447435045
Name:WILKS, ROSCOE JR (DMD)
Entity type:Individual
Prefix:DR
First Name:ROSCOE
Middle Name:
Last Name:WILKS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 JASMINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70122-6017
Mailing Address - Country:US
Mailing Address - Phone:504-304-0472
Mailing Address - Fax:
Practice Address - Street 1:2619 JASMINE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70122-6017
Practice Address - Country:US
Practice Address - Phone:504-304-0472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA37971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1837971Medicaid