MEDICARE: DR. JEREMY T WILSON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5090	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023186095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY T WILSON DMD

Provider Business Mailing Address
First Line	:	526 S TONOPAH DR
Second Line	:	STE. 200
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4043
Country	:	US
Telephone Number	:	702-291-2031
Fax Number	:	702-366-1483

Provider Business Practice Location Address
First Line	:	2301 E LAKE MEAD BLVD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7137
Country	:	US
Telephone Number	:	702-331-8338
Fax Number	:	702-639-0579

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	06/15/2016

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