Basic Information
| Provider Information | |||||||||
| NPI: | 1376975680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDING | ||||||||
| FirstName: | JAKE | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | TINGAY DENTAL CLINIC | ||||||||
| Address2: | 320 W HOSPITAL RD | ||||||||
| City: | FT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067875102 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | TINGAY DENTAL CLINIC | ||||||||
| Address2: | 320 W HOSPITAL RD | ||||||||
| City: | FT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067875102 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2013 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 8726975-9922 | UT | Y | Dental Providers | Dentist |
No ID Information.