Provider Demographics
NPI:1770569691
Name:WENTZ, WILLARD WILLIAM JR (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLARD
Middle Name:WILLIAM
Last Name:WENTZ
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 RISON ST
Mailing Address - Street 2:STRATFORD MEDICAL PLAZA
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2458
Mailing Address - Country:US
Mailing Address - Phone:434-792-5134
Mailing Address - Fax:434-791-2919
Practice Address - Street 1:501 RISON ST
Practice Address - Street 2:STRATFORD MEDICAL PLAZA
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2458
Practice Address - Country:US
Practice Address - Phone:434-792-5134
Practice Address - Fax:434-791-2919
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04380001711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA050010OtherANTHEM ID
NC899-9122OtherNC MEDICAID
VAT21703Medicare UPIN