Healthcare Provider Details

I. General information

NPI: 1679163083
Provider Name (Legal Business Name): C. EDWIN WENTZ DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W JOE HARVEY BLVD
HOBBS NM
88240-0907
US

IV. Provider business mailing address

4013 84TH ST
LUBBOCK TX
79423-1913
US

V. Phone/Fax

Practice location:
  • Phone: 575-393-6047
  • Fax:
Mailing address:
  • Phone: 806-794-8124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. C. EDWIN WENTZ
Title or Position: OWNER
Credential: DDS
Phone: 806-794-8124