Provider Demographics
NPI:1316002314
Name:WILSON, JACK (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
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 1:29452 N 49TH WAY
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-3323
Mailing Address - Country:US
Mailing Address - Phone:480-262-4412
Mailing Address - Fax:
Practice Address - Street 1:12320 N 32ND ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7154
Practice Address - Country:US
Practice Address - Phone:602-992-1384
Practice Address - Fax:602-992-6104
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6410122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist