Provider Demographics
NPI:1427215441
Name:JOHN A. WILDE D.D.S. INC.
Entity Type:Organization
Organization Name:JOHN A. WILDE D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:319-524-1477
Mailing Address - Street 1:1626 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-3424
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:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3424
Practice Address - Country:US
Practice Address - Phone:319-524-1477
Practice Address - Fax:319-524-7965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA05824174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA05824OtherIOWA DENTAL LICENSE
IA38071OtherBCBS PROVIDER#
IA1089326Medicaid
IA1089326Medicaid