Provider Demographics
NPI:1083464762
Name:WILSON, JAZMINE MARIE (RDH)
Entity type:Individual
Prefix:
First Name:JAZMINE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 E BRANHAM LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-0008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4041 N CENTRAL AVE BLDG C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3313
Practice Address - Country:US
Practice Address - Phone:602-279-5262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH010646124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty