Provider Demographics
NPI:1093948416
Name:DANFORTH, WESLEY IRVING (RDH)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:IRVING
Last Name:DANFORTH
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:BRYANT POND
Mailing Address - State:ME
Mailing Address - Zip Code:04219-6831
Mailing Address - Country:US
Mailing Address - Phone:207-333-2089
Mailing Address - Fax:
Practice Address - Street 1:18 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:BRYANT POND
Practice Address - State:ME
Practice Address - Zip Code:04219-6831
Practice Address - Country:US
Practice Address - Phone:207-333-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3659124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME434553499Medicaid