Provider Demographics
NPI:1780775130
Name:WILDT, LARRY (DDS)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WILDT
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 1:1344 WINTERWOOD DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-3441
Mailing Address - Country:US
Mailing Address - Phone:616-364-9348
Mailing Address - Fax:616-364-5950
Practice Address - Street 1:2515 ALPINE AVE NW
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1924
Practice Address - Country:US
Practice Address - Phone:616-364-9348
Practice Address - Fax:616-364-5950
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI113651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice