Provider Demographics
NPI:1922673599
Name:WILDE, LEWIS CLARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:CLARK
Last Name:WILDE
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 1:2001 MARIYANA AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5627
Mailing Address - Country:US
Mailing Address - Phone:435-669-0156
Mailing Address - Fax:
Practice Address - Street 1:1601 S SECOND ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5816
Practice Address - Country:US
Practice Address - Phone:505-722-4422
Practice Address - Fax:505-722-2060
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5467122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program