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General NPI Number Information
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NPI Number | 1043500648
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Entity Type | Individual
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Provider Name | JUSTIN RICHARD WILD D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 04/15/2011
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Last Update Date | 12/23/2025
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Provider Practice Location Address
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Address Line | 11800 SINGLETREE LN
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-5328
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Country | US
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Telephone | 952-237-8619
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Fax |
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Provider Business Mailing Address
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Address Line | 9651 WYOMING TER S
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City | BLOOMINGTON
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State | MN
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Zip | 55438-1606
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Country | US
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Telephone | 952-237-8619
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D13192
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License Number State | MN
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