Provider Demographics
NPI:1245644590
Name:WILD, LAURA (DDS)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 DUNLAP ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4201
Mailing Address - Country:US
Mailing Address - Phone:651-290-9200
Mailing Address - Fax:
Practice Address - Street 1:409 DUNLAP ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4201
Practice Address - Country:US
Practice Address - Phone:651-290-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-15
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND134191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice