Provider Demographics
NPI:1871155788
Name:PAUL R WILD DDS PA
Entity type:Organization
Organization Name:PAUL R WILD DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WILD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-452-0261
Mailing Address - Street 1:750 MAIN ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55118
Mailing Address - Country:US
Mailing Address - Phone:651-452-0261
Mailing Address - Fax:651-452-6109
Practice Address - Street 1:750 MAIN ST
Practice Address - Street 2:SUITE 215
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55118
Practice Address - Country:US
Practice Address - Phone:651-452-0261
Practice Address - Fax:651-452-6109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-01
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty