Provider Demographics
NPI:1902008865
Name:WILDER, IRVIN LARRY (DDS)
Entity Type:Individual
Prefix:
First Name:IRVIN
Middle Name:LARRY
Last Name:WILDER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9015 #1 LIBERTY RD.
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133
Mailing Address - Country:US
Mailing Address - Phone:410-922-6800
Mailing Address - Fax:410-922-6801
Practice Address - Street 1:9015 #1 LIBERTY RD.
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133
Practice Address - Country:US
Practice Address - Phone:410-922-6800
Practice Address - Fax:410-922-6801
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5877122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist