Individual
JERMAINE WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1732 OLD COUNTRY RD UNIT D, RIVERHEAD, NY 11901-3104
(631) 381-6205
Mailing address
1732 OLD COUNTRY RD UNIT D, RIVERHEAD, NY 11901-3104
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
063526
NY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
05/02/2022
Last updated
09/21/2023
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