Provider Demographics
NPI:1770765257
Name:WILFONG, DANIEL KELLY (DDS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:KELLY
Last Name:WILFONG
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 1:2905 DUDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101
Mailing Address - Country:US
Mailing Address - Phone:304-424-5002
Mailing Address - Fax:304-422-5740
Practice Address - Street 1:2905 DUDLEY AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101
Practice Address - Country:US
Practice Address - Phone:304-424-5002
Practice Address - Fax:304-422-5740
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022126122300000X
WV3699122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist