Provider Demographics
NPI:1265501316
Name:WILDE, JOHN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:WILDE
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 1:1626 MORGAN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632
Mailing Address - Country:US
Mailing Address - Phone:319-524-1477
Mailing Address - Fax:319-524-7965
Practice Address - Street 1:1626 MORGAN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632
Practice Address - Country:US
Practice Address - Phone:319-524-1477
Practice Address - Fax:319-524-7965
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA058241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA05824OtherIA DENTAL LICENSE
IA1089326Medicaid
38071OtherBLUE CROSS
38071OtherBLUE CROSS