Individual
SPENCER K. WILDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
625 W SOUTHERN AVE STE E-145, MESA, AZ 85210-5030
(480) 710-8081
(866) 814-1886
Mailing address
PMB 351, 6890 E. SUNRISE DR. STE 120, TUCSON, AZ 85750-0739
(520) 730-6467
(520) 529-2938
Taxonomy
Speciality
Code
Description
License number
State
1223D0004X
Dental Anesthesiology
25894
TX
1223D0004X
Dental Anesthesiology
Primary
D5497
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
863573
AHCCCS PROVIDER ID
AZ
01
—
884644
AHCCCS PROVIDER ID DSDA
AZ
Enumeration date
12/04/2006
Last updated
07/01/2016
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