Provider Demographics
NPI:1669561239
Name:WILDE, ELGIN WADE (DMD)
Entity type:Individual
Prefix:DR
First Name:ELGIN
Middle Name:WADE
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 1:2900 CENTRAL AVE, BLDG 1
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-6686
Mailing Address - Country:US
Mailing Address - Phone:406-656-6100
Mailing Address - Fax:406-656-8726
Practice Address - Street 1:2900 CENTRAL AVE, BLDG 1
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6686
Practice Address - Country:US
Practice Address - Phone:406-656-6100
Practice Address - Fax:406-656-8726
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice