Provider Demographics
NPI:1336694116
Name:WILSON, JARELL LAMONZ (DDS)
Entity Type:Individual
Prefix:DR
First Name:JARELL
Middle Name:LAMONZ
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 681
Mailing Address - Street 2:
Mailing Address - City:PINON
Mailing Address - State:AZ
Mailing Address - Zip Code:86510-0681
Mailing Address - Country:US
Mailing Address - Phone:843-593-5905
Mailing Address - Fax:
Practice Address - Street 1:NAVAJO SERVICE RTE 41
Practice Address - Street 2:
Practice Address - City:PINON
Practice Address - State:AZ
Practice Address - Zip Code:86510
Practice Address - Country:US
Practice Address - Phone:928-725-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0594611223G0001X
AZD010564390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program