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General NPI Number Information
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NPI Number | 1487829800
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Entity Type | Organization
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Legal Business Name | MARC W WILD DDS INC
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Dates
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Enumeration Date | 04/26/2008
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Last Update Date | 04/26/2008
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Provider Practice Location Address
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Address Line | 1104 5TH AVE
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City | HUNTINGTON
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State | WV
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Zip | 25701-2205
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Country | US
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Telephone | 304-523-8671
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Fax | 304-523-8674
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Provider Business Mailing Address
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Address Line | 1104 5TH AVE
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City | HUNTINGTON
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State | WV
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Zip | 25701-2205
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Country | US
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Telephone | 304-523-8671
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Fax | 304-523-8674
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARC WILLIAM WILD
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Credential | DDS
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Telephone | 304-523-8671
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 2466
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License Number State | WV
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