Provider Demographics
NPI:1710274071
Name:WENTWORTH, CONSTANCE JIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:JIN
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LIMESTONE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7091
Mailing Address - Country:US
Mailing Address - Phone:716-675-6204
Mailing Address - Fax:716-675-4841
Practice Address - Street 1:19 LIMESTONE DR STE 2
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7091
Practice Address - Country:US
Practice Address - Phone:716-675-6204
Practice Address - Fax:716-675-4841
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0564811223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics