Provider Demographics
NPI:1598988792
Name:FENWICK, JOSEPH WYETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WYETH
Last Name:FENWICK
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:PO BOX 2544
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606
Mailing Address - Country:US
Mailing Address - Phone:419-536-5467
Mailing Address - Fax:
Practice Address - Street 1:3425 EXECUTIVE PARKWAY
Practice Address - Street 2:SUITE 214
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606
Practice Address - Country:US
Practice Address - Phone:419-536-8332
Practice Address - Fax:419-537-6746
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30013405122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0163826Medicaid