Provider Demographics
NPI:1023186095
Name:WILSON, JEREMY T (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:T
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 S TONOPAH DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4043
Mailing Address - Country:US
Mailing Address - Phone:702-291-2031
Mailing Address - Fax:702-366-1483
Practice Address - Street 1:2301 E LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7137
Practice Address - Country:US
Practice Address - Phone:702-331-8338
Practice Address - Fax:702-639-0579
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5090122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1023186095Medicaid
NV100510344Medicaid