Provider Demographics
NPI:1659580249
Name:WILDWOOD DENTAL GROUP
Entity Type:Organization
Organization Name:WILDWOOD DENTAL GROUP
Other - Org Name:BECK HAYRE SKIBIEL AND BERRY PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-368-0611
Mailing Address - Street 1:1617 183RD ST SE STE 1
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6812
Mailing Address - Country:US
Mailing Address - Phone:425-368-0600
Mailing Address - Fax:425-788-3285
Practice Address - Street 1:1617 183RD ST SE STE 1
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-6812
Practice Address - Country:US
Practice Address - Phone:425-368-0600
Practice Address - Fax:425-788-3285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 049011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty