Provider Demographics
NPI:1578663589
Name:MANN, DEWEY WILSON JR (DDS)
Entity Type:Individual
Prefix:
First Name:DEWEY
Middle Name:WILSON
Last Name:MANN
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 1:104 GOFF MTN RD
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313
Mailing Address - Country:US
Mailing Address - Phone:304-776-6992
Mailing Address - Fax:304-776-6992
Practice Address - Street 1:104 GOFF MTN RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313
Practice Address - Country:US
Practice Address - Phone:304-776-6992
Practice Address - Fax:304-776-6992
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0135558000Medicaid