Provider Demographics
NPI:1083055305
Name:WILDE, BRIAN ROBERT (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ROBERT
Last Name:WILDE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W INA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3115
Mailing Address - Country:US
Mailing Address - Phone:575-522-1779
Mailing Address - Fax:520-742-1232
Practice Address - Street 1:1320 W INA RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3115
Practice Address - Country:US
Practice Address - Phone:520-742-1232
Practice Address - Fax:520-742-0925
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0105291223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty