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General NPI Number Information
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NPI Number | 1376975680
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Entity Type | Individual
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Provider Name | JAKE THOMAS WILDING D.D.S
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Gender | Male
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Dates
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Enumeration Date | 08/09/2013
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Last Update Date | 09/23/2025
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Provider Practice Location Address
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Address Line | US ARMY DENTAL HEALTH ACTIVITY 36000 SHOEMAKER LANE, SUITE 1051
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City | FORT CAVAZOS
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State | TX
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Zip | 76544-7654
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Country | US
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Telephone | 254-287-3105
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 844658
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City | DALLAS
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State | TX
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Zip | 75284-4658
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Country | US
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Telephone | 800-994-0371
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 39234
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 8726975-9922
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License Number State | UT
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8726975-9922
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License Number State | UT
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Taxonomy #4
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 39234
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License Number State | TX
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