Provider Demographics
NPI:1912916461
Name:WIGGINS, JEREMY C (DDS)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:C
Last Name:WIGGINS
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 1:3326 4TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4455
Mailing Address - Country:US
Mailing Address - Phone:208-743-2505
Mailing Address - Fax:208-746-6395
Practice Address - Street 1:3326 4TH ST STE 4
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4455
Practice Address - Country:US
Practice Address - Phone:208-743-2505
Practice Address - Fax:208-746-6395
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-34941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5039532Medicaid
ID806332400Medicaid