Provider Demographics
NPI:1427049212
Name:WILDER, BARRY STUART (DDS)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:STUART
Last Name:WILDER
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 1:805 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2504
Mailing Address - Country:US
Mailing Address - Phone:631-732-0233
Mailing Address - Fax:631-732-0247
Practice Address - Street 1:805 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2504
Practice Address - Country:US
Practice Address - Phone:631-732-0233
Practice Address - Fax:631-732-0247
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030059122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0065Z759Medicaid