=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750803300
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENT R WILDERN DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4701 PLAINFIELD AVE NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-1644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-364-8716
-----------------------------------------------------
Fax | 616-364-8716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4701 PLAINFIELD AVE NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-1644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-364-8716
-----------------------------------------------------
Fax | 616-364-8829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KENT RAYMOND WILDERN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 616-364-8716
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------