Provider Demographics
NPI:1922028620
Name:WILDE, WILLIAM ROY (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROY
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:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:TROUT LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98650-0385
Mailing Address - Country:US
Mailing Address - Phone:509-395-2002
Mailing Address - Fax:
Practice Address - Street 1:12711 SE MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6053
Practice Address - Country:US
Practice Address - Phone:360-896-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000090161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice