Provider Demographics
NPI:1780099788
Name:WILDE, BRADEN (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:BRADEN
Middle Name:
Last Name:WILDE
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1282 E QUAIL GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6562
Mailing Address - Country:US
Mailing Address - Phone:385-539-1055
Mailing Address - Fax:
Practice Address - Street 1:1400 S FOOTHILL DR STE 240
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-2300
Practice Address - Country:US
Practice Address - Phone:801-581-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-45921223G0001X
UT6258159-99221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice