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General NPI Number Information
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NPI Number | 1497845523
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Entity Type | Organization
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Legal Business Name | GREGGORY S. WILDE, DDS, PS
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3594 NW LOWELL ST
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City | SILVERDALE
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State | WA
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Zip | 98383-9116
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Country | US
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Telephone | 360-692-0300
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Fax | 360-698-2988
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Provider Business Mailing Address
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Address Line | PO BOX 1970
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City | SILVERDALE
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State | WA
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Zip | 98383-1970
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Country | US
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Telephone | 360-692-0300
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Fax | 360-698-2988
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GREGGORY WAYNE SCOTT WILDE
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Credential | DDS
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Telephone | 360-692-0300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DE00004274
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License Number State | WA
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