Provider Demographics
NPI:1972296481
Name:WILD CHILD ORTHODONTICS
Entity type:Organization
Organization Name:WILD CHILD ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-903-9484
Mailing Address - Street 1:11800 SINGLETREE LN STE 200
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5397
Mailing Address - Country:US
Mailing Address - Phone:952-903-9484
Mailing Address - Fax:952-941-7091
Practice Address - Street 1:17677 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-2250
Practice Address - Country:US
Practice Address - Phone:952-903-9484
Practice Address - Fax:952-941-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental