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General NPI Number Information
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NPI Number | 1336694116
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Entity Type | Individual
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Provider Name | JARELL LAMONZ WILSON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/22/2016
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Last Update Date | 02/25/2020
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Provider Practice Location Address
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Address Line | NAVAJO SERVICE RTE 41
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City | PINON
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State | AZ
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Zip | 86510
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Country | US
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Telephone | 928-725-9500
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 681
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City | PINON
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State | AZ
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Zip | 86510-0681
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Country | US
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Telephone | 843-593-5905
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 059461
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | D010564
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License Number State | AZ
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