Provider Demographics
NPI:1043606114
Name:WOOD, JEREMY DON (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DON
Last Name:WOOD
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 1:310 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-4708
Mailing Address - Country:US
Mailing Address - Phone:912-537-3377
Mailing Address - Fax:912-538-7010
Practice Address - Street 1:310 JACKSON ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4708
Practice Address - Country:US
Practice Address - Phone:912-537-3377
Practice Address - Fax:912-538-7010
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013906122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist