Provider Demographics
NPI:1619386216
Name:WERMUTH, WESLEY D (DDS)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:D
Last Name:WERMUTH
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 1:1325 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3945
Mailing Address - Country:US
Mailing Address - Phone:208-709-6280
Mailing Address - Fax:
Practice Address - Street 1:433 30TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-2807
Practice Address - Country:US
Practice Address - Phone:503-338-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program