Provider Demographics
NPI:1790483444
Name:HARGETT, WESLEY MATTHEW
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:MATTHEW
Last Name:HARGETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340B HAWAII AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-3516
Mailing Address - Country:US
Mailing Address - Phone:334-782-1755
Mailing Address - Fax:
Practice Address - Street 1:6145 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5558
Practice Address - Country:US
Practice Address - Phone:270-412-2787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39904122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist