Healthcare Provider Details

I. General information

NPI: 1023563921
Provider Name (Legal Business Name): WAYNE DENTAL - VALLEY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2016
Last Update Date: 08/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KENOVA AVE
WAYNE WV
25570-9795
US

IV. Provider business mailing address

203 KENOVA AVE
WAYNE WV
25570-9795
US

V. Phone/Fax

Practice location:
  • Phone: 304-272-5136
  • Fax: 304-272-3807
Mailing address:
  • Phone: 304-272-5136
  • Fax: 304-272-3807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateWV

VIII. Authorized Official

Name: RICHARD WEINBERGER
Title or Position: CFO
Credential:
Phone: 304-525-3334