Provider Demographics
NPI:1376975680
Name:WILDING, JAKE THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:THOMAS
Last Name:WILDING
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:
Practice Address - Street 1:US ARMY DENTAL HEALTH ACTIVITY
Practice Address - Street 2:36000 SHOEMAKER LANE, SUITE 1051
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544-7654
Practice Address - Country:US
Practice Address - Phone:254-287-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8726975-9922122300000X, 1223P0700X
TX39234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist