Healthcare Provider Details

I. General information

NPI: 1114297017
Provider Name (Legal Business Name): ROBERT GEORGE WERTZ JR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 NORMAN DR
LEBANON PA
17042-7445
US

IV. Provider business mailing address

855 NORMAN DR
LEBANON PA
17042-7445
US

V. Phone/Fax

Practice location:
  • Phone: 717-273-9780
  • Fax:
Mailing address:
  • Phone: 717-273-9780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS037677
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: