Provider Demographics
NPI:1003999749
Name:WILDMAN, RICHARD DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:WILDMAN
Suffix:
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:PO BOX 2249
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638
Mailing Address - Country:US
Mailing Address - Phone:208-634-7071
Mailing Address - Fax:208-634-7071
Practice Address - Street 1:210 PARK STREET
Practice Address - Street 2:RICHARD D WILDMAN
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-2249
Practice Address - Country:US
Practice Address - Phone:208-634-7071
Practice Address - Fax:208-634-7071
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist