Provider Demographics
NPI:1457466013
Name:WILDE, LISA KAREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KAREN
Last Name:WILDE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W TRINITY ST
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-9561
Mailing Address - Country:US
Mailing Address - Phone:972-564-3371
Mailing Address - Fax:972-329-0019
Practice Address - Street 1:1515 E KEARNEY ST STE 101
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2688
Practice Address - Country:US
Practice Address - Phone:972-329-0018
Practice Address - Fax:972-329-0019
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX172431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice