Provider Demographics
NPI:1023852845
Name:WILDE, MEGAN PETERSON (DDS)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:PETERSON
Last Name:WILDE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:NICOLE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1399 W ULTAR DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6925
Mailing Address - Country:US
Mailing Address - Phone:801-870-3361
Mailing Address - Fax:
Practice Address - Street 1:16145 N HIGH DESERT ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5510
Practice Address - Country:US
Practice Address - Phone:855-433-6825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-56471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice