Provider Demographics
NPI:1720152960
Name:WILEY, M JACK (DDS)
Entity type:Individual
Prefix:
First Name:M
Middle Name:JACK
Last Name:WILEY
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 1:1700 NW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98026
Mailing Address - Country:US
Mailing Address - Phone:206-783-0400
Mailing Address - Fax:206-783-1929
Practice Address - Street 1:1700 NW 56TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98026
Practice Address - Country:US
Practice Address - Phone:206-783-0400
Practice Address - Fax:206-783-1929
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice