Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 30.023002 | OH |
NPI | 1104060540 |
---|---|
Provider Name | Dr. Jeremy Wilde |
First Address | Euclid, OH 44132-3703 |
Second Address | Euclid, OH 44132-3703 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/04/2009 |
Last Update Date | 16/05/2013 |