Healthcare Provider Details

I. General information

NPI: 1437824448
Provider Name (Legal Business Name): MR. DUSTIN GARRETT WILDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 FOOTHILLS DR
FARMINGTON NM
87402-8279
US

IV. Provider business mailing address

1401 CHERRY LN
FARMINGTON NM
87401-7409
US

V. Phone/Fax

Practice location:
  • Phone: 505-599-8604
  • Fax:
Mailing address:
  • Phone: 505-278-3252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: