Provider Demographics
NPI:1891217246
Name:WENTWORTH, NICHOLAS D (DMD)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:D
Last Name:WENTWORTH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 WILLIAMSON RD STE 104
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5945
Mailing Address - Country:US
Mailing Address - Phone:704-660-5955
Mailing Address - Fax:
Practice Address - Street 1:367 WILLIAMSON RD STE 104
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5945
Practice Address - Country:US
Practice Address - Phone:704-660-5955
Practice Address - Fax:704-660-5299
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC107451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice