Provider Demographics
NPI:1710097514
Name:WILDE, ROBERT CARL (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CARL
Last Name:WILDE
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 1:14800 SW BULL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-1233
Mailing Address - Country:US
Mailing Address - Phone:503-590-1480
Mailing Address - Fax:
Practice Address - Street 1:201 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2727
Practice Address - Country:US
Practice Address - Phone:503-538-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5798122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist