Provider Demographics
NPI:1104993591
Name:WILDE, MARK I (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:I
Last Name:WILDE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5280 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33351-5018
Mailing Address - Country:US
Mailing Address - Phone:954-749-4594
Mailing Address - Fax:954-578-9575
Practice Address - Street 1:5280 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33351-5018
Practice Address - Country:US
Practice Address - Phone:954-749-4594
Practice Address - Fax:954-578-9575
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9814122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist