Provider Demographics
NPI:1114556115
Name:WILSON, WREMAINE LUMASS DUPREE (DDS)
Entity type:Individual
Prefix:
First Name:WREMAINE
Middle Name:LUMASS DUPREE
Last Name:WILSON
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 1:16579 W LATHAM ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-6198
Mailing Address - Country:US
Mailing Address - Phone:619-384-2386
Mailing Address - Fax:
Practice Address - Street 1:825 S WATSON RD STE 101
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-3435
Practice Address - Country:US
Practice Address - Phone:623-386-7319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZD0109411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program