1003999749 NPI number — RICHARD DAVID WILDMAN DMD

Table of content: RICHARD DAVID WILDMAN DMD (NPI 1003999749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003999749 NPI number — RICHARD DAVID WILDMAN DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDMAN
Provider First Name:
RICHARD
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003999749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCALL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-634-7071
Provider Business Mailing Address Fax Number:
208-634-7071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 PARK STREET
Provider Second Line Business Practice Location Address:
RICHARD D WILDMAN
Provider Business Practice Location Address City Name:
MCCALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83638-2249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-634-7071
Provider Business Practice Location Address Fax Number:
208-634-7071
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D1375 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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