Healthcare Provider Details

I. General information

NPI: 1437146768
Provider Name (Legal Business Name): TODD GILBERT WAHLIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W CASABLANCA CANNON AFB BUILDING1400
CLOVIS NM
88103-5014
US

IV. Provider business mailing address

208 W CASABLANCA CANNON AFB BUILDING1400
CLOVIS NM
88103-5014
US

V. Phone/Fax

Practice location:
  • Phone: 505-784-6608
  • Fax: 505-784-6028
Mailing address:
  • Phone: 505-784-6608
  • Fax: 505-784-6028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2459
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: