Provider Demographics
NPI:1477130821
Name:WENTZ, DALTON (OD)
Entity type:Individual
Prefix:DR
First Name:DALTON
Middle Name:
Last Name:WENTZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 KOEHLER DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1208
Mailing Address - Country:US
Mailing Address - Phone:304-941-7614
Mailing Address - Fax:
Practice Address - Street 1:4202 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2502
Practice Address - Country:US
Practice Address - Phone:304-925-4761
Practice Address - Fax:304-925-0310
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2024-09-09
Deactivation Date:2024-08-05
Deactivation Code:
Reactivation Date:2024-08-20
Provider Licenses
StateLicense IDTaxonomies
172V00000X
WV3039-IOD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No172V00000XOther Service ProvidersCommunity Health Worker