Provider Demographics
NPI:1669511572
Name:WILD, LAWRENCE ERNEST (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:ERNEST
Last Name:WILD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 FRUITVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-1926
Mailing Address - Country:US
Mailing Address - Phone:941-366-0134
Mailing Address - Fax:941-404-1760
Practice Address - Street 1:1231 N TUTTLE AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-3116
Practice Address - Country:US
Practice Address - Phone:941-366-0134
Practice Address - Fax:866-622-3009
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13270122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075192800Medicaid