Individual
JAY WICKERSHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
12926 US HIGHWAY 301 S STE 5, RIVERVIEW, FL 33578-7458
(217) 540-5100
Mailing address
12926 US HIGHWAY 301 S STE 5, RIVERVIEW, FL 33578-7458
(217) 540-5100
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DN25056
FL
Other
Enumeration date
07/06/2020
Last updated
07/06/2020
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