Individual
DR. LEWIS CLARK WILDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1601 S SECOND ST, GALLUP, NM 87301-5816
(505) 722-4422
(505) 722-2060
Mailing address
2001 MARIYANA AVE, GALLUP, NM 87301-5627
(435) 669-0156
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DD5467
NM
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
05/25/2021
Last updated
07/06/2021
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