Provider Demographics
NPI:1831107606
Name:WILD, DENNIS E (DC)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:E
Last Name:WILD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 TORRANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3325
Mailing Address - Country:US
Mailing Address - Phone:310-316-1613
Mailing Address - Fax:310-543-2718
Practice Address - Street 1:414 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3325
Practice Address - Country:US
Practice Address - Phone:310-316-1613
Practice Address - Fax:310-543-2718
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14811111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC14810Medicare ID - Type Unspecified
T17896Medicare UPIN