Provider Demographics
NPI:1558585521
Name:WOODWORTH, EDWARD JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JON
Last Name:WOODWORTH
Suffix:
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 1:10346 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:NY
Mailing Address - Zip Code:14031-1604
Mailing Address - Country:US
Mailing Address - Phone:716-759-8306
Mailing Address - Fax:716-759-2114
Practice Address - Street 1:10346 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031-1604
Practice Address - Country:US
Practice Address - Phone:716-759-8306
Practice Address - Fax:716-759-2114
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY43536122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01350889Medicaid
NY4000538OtherINDEPENDENT HEALTH