Provider Demographics
NPI:1558451864
Name:WILDER, JAMES ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
Last Name:WILDER
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 1:3702 ENSIGN RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5054
Mailing Address - Country:US
Mailing Address - Phone:360-491-5990
Mailing Address - Fax:360-491-5992
Practice Address - Street 1:3702 ENSIGN RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5054
Practice Address - Country:US
Practice Address - Phone:360-491-5990
Practice Address - Fax:360-491-5992
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007459122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist