Provider Demographics
NPI:1619991924
Name:WILSON, LOREN JAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:LOREN
Middle Name:JAY
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 1:10 KELLY ROAD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139
Mailing Address - Country:US
Mailing Address - Phone:617-803-0887
Mailing Address - Fax:617-661-4894
Practice Address - Street 1:2331 MASSACHUSETTS AVENUE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140
Practice Address - Country:US
Practice Address - Phone:617-876-8636
Practice Address - Fax:617-661-4894
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA144181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice