Provider Demographics
NPI:1124543517
Name:WILDES, MICHELE (RDH)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:WILDES
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 AFFIRMED DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-4416
Mailing Address - Country:US
Mailing Address - Phone:608-931-6119
Mailing Address - Fax:
Practice Address - Street 1:2725 AFFIRMED DRIVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-4416
Practice Address - Country:US
Practice Address - Phone:608-931-6119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9737-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9737-16OtherREGISTERED DENTAL HYGIENIST