Provider Demographics
NPI:1104060540
Name:WILDE, JEREMY (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:WILDE
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26300 EUCLID AVE STE 620
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-3703
Mailing Address - Country:US
Mailing Address - Phone:216-261-6464
Mailing Address - Fax:216-261-6465
Practice Address - Street 1:26300 EUCLID AVE STE 620
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-3703
Practice Address - Country:US
Practice Address - Phone:216-261-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0230021223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics