1659431013 NPI number — WALLACE S. WILDER MD

Table of content: DR. DAVID JOHN COBB DDS (NPI 1578536934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659431013 NPI number — WALLACE S. WILDER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLACE S. WILDER MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1659431013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 SUNNYVIEW LN
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
KALISPELL
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59901-3135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-752-8300
Provider Business Mailing Address Fax Number:
406-752-3542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 SUNNYVIEW LN
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901-3135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-752-8300
Provider Business Practice Location Address Fax Number:
406-752-3542
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WAGGENER
Authorized Official First Name:
TRUDY
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
406-752-8300

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  3655 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0032344 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 92168 . This is a "BCBS - MICHAEL SCHWALLER" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0437529 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08110 . This is a "BCBS - WALLACE WILDER MD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 371330 . This is a "BCBS - VALERIE BEEBE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0066495 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95755 . This is a "BCBS - LYNN A. DYKSTRA MD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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