Healthcare Provider Details

I. General information

NPI: 1336286129
Provider Name (Legal Business Name): JEFFREY L. WILDEN D.D.S.,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 W BROAD ST
COLUMBUS OH
43222-1043
US

IV. Provider business mailing address

1531 W BROAD ST
COLUMBUS OH
43222-1043
US

V. Phone/Fax

Practice location:
  • Phone: 614-351-0555
  • Fax: 614-351-0763
Mailing address:
  • Phone: 614-351-0555
  • Fax: 614-351-0763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19204
License Number StateOH

VIII. Authorized Official

Name: DR. JEFFREY L WILDEN
Title or Position: OFFICER
Credential: D.D.S.
Phone: 614-351-0555