Provider Demographics
NPI:1407487408
Name:WILDE ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:WILDE ORTHODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:520-742-1232
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:520-742-1232
Mailing Address - Fax:520-742-0925
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty