=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952514689
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGGORY S WILDE III D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3594 NW LOWELL ST
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-9116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-692-0300
-----------------------------------------------------
Fax | 360-698-2998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6731 KITSAP WAY
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98312-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-373-1876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------