Healthcare Provider Details

I. General information

NPI: 1922673599
Provider Name (Legal Business Name): LEWIS CLARK WILDE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S SECOND ST
GALLUP NM
87301-5816
US

IV. Provider business mailing address

2001 MARIYANA AVE
GALLUP NM
87301-5627
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-4422
  • Fax: 505-722-2060
Mailing address:
  • Phone: 435-669-0156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5467
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: