Healthcare Provider Details

I. General information

NPI: 1316321540
Provider Name (Legal Business Name): DUSTIN WYLDE D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S ROSELLE RD SUITE D
SCHAUMBURG IL
60193-5594
US

IV. Provider business mailing address

140 S ROSELLE RD SUITE D
SCHAUMBURG IL
60193-5594
US

V. Phone/Fax

Practice location:
  • Phone: 847-895-8565
  • Fax:
Mailing address:
  • Phone: 847-895-8565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019030312
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: