Provider Demographics
NPI:1093792954
Name:WIRTH, DAVID BRENT (MA, MS)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:BRENT
Last Name:WIRTH
Suffix:
Gender:M
Credentials:MA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 OAKBROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-7097
Mailing Address - Country:US
Mailing Address - Phone:937-255-5227
Mailing Address - Fax:937-656-7617
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:88 MDG SGOS/SGCXL
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5546
Practice Address - Country:US
Practice Address - Phone:937-787-9280
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist