Provider Demographics
NPI:1225145501
Name:WILD, PAUL W (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:W
Last Name:WILD
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 1:750 HIGHWAY 110
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1512
Mailing Address - Country:US
Mailing Address - Phone:651-452-0261
Mailing Address - Fax:
Practice Address - Street 1:750 HIGHWAY 110
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1512
Practice Address - Country:US
Practice Address - Phone:651-452-0261
Practice Address - Fax:651-452-6109
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 94901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice