Provider Demographics
NPI:1336286129
Name:JEFFREY L. WILDEN D.D.S.,INC.
Entity Type:Organization
Organization Name:JEFFREY L. WILDEN D.D.S.,INC.
Other - Org Name:FRANKLINTON DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-351-0555
Mailing Address - Street 1:1531 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1043
Mailing Address - Country:US
Mailing Address - Phone:614-351-0555
Mailing Address - Fax:614-351-0763
Practice Address - Street 1:1531 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1043
Practice Address - Country:US
Practice Address - Phone:614-351-0555
Practice Address - Fax:614-351-0763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
OH192041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2272777Medicaid