Provider Demographics
NPI:1437824448
Name:WILDER, DUSTIN GARRETT
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:GARRETT
Last Name:WILDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-7409
Mailing Address - Country:US
Mailing Address - Phone:505-278-3252
Mailing Address - Fax:
Practice Address - Street 1:5300 FOOTHILLS DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-8279
Practice Address - Country:US
Practice Address - Phone:505-599-8604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool