Provider Demographics
NPI:1497845523
Name:GREGGORY S. WILDE, DDS, PS
Entity Type:Organization
Organization Name:GREGGORY S. WILDE, DDS, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGGORY
Authorized Official - Middle Name:WAYNE SCOTT
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-692-0300
Mailing Address - Street 1:PO BOX 1970
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-1970
Mailing Address - Country:US
Mailing Address - Phone:360-692-0300
Mailing Address - Fax:360-698-2988
Practice Address - Street 1:3594 NW LOWELL ST
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9116
Practice Address - Country:US
Practice Address - Phone:360-692-0300
Practice Address - Fax:360-698-2988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000042741223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty