Basic Information
| Provider Information | |||||||||
| NPI: | 1114556115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | WREMAINE | ||||||||
| MiddleName: | LUMASS DUPREE | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16579 W LATHAM ST | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853386198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193842386 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 825 S WATSON RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853263435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233867319 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2020 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | D010941 | AZ | Y | Dental Providers | Dentist | General Practice |
No ID Information.