Healthcare Provider Details

I. General information

NPI: 1336694116
Provider Name (Legal Business Name): JARELL LAMONZ WILSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MEDICINE WAY RD
PERIDOT AZ
85542-5000
US

IV. Provider business mailing address

360 S MELLONVILLE AVE
SANFORD FL
32771-1453
US

V. Phone/Fax

Practice location:
  • Phone: 928-475-1495
  • Fax:
Mailing address:
  • Phone: 843-593-5905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD010564
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number059461
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN31327
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD010564
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: