Provider Demographics
NPI:1871925008
Name:CHABALLA-WILDE, AMY (DMD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:CHABALLA-WILDE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N POINTE BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4134
Mailing Address - Country:US
Mailing Address - Phone:717-581-9394
Mailing Address - Fax:717-581-9308
Practice Address - Street 1:160 N POINTE BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4134
Practice Address - Country:US
Practice Address - Phone:717-581-9394
Practice Address - Fax:717-581-9308
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027636L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist