Provider Demographics
NPI:1396167862
Name:WANO, JEREMY DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DAVID
Last Name:WANO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WAHOO DRIVE
Mailing Address - Street 2:NAVAL BRANCH HEALTH CLINIC
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349
Mailing Address - Country:US
Mailing Address - Phone:860-649-3129
Mailing Address - Fax:
Practice Address - Street 1:75 STEAMBOAT WHARF
Practice Address - Street 2:APT 35
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2546
Practice Address - Country:US
Practice Address - Phone:724-787-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8774121-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice