Provider Demographics
NPI:1881743334
Name:WIDNER, DANE B (DDS)
Entity type:Individual
Prefix:DR
First Name:DANE
Middle Name:B
Last Name:WIDNER
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 1:1205 HAWTHORNE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-1438
Mailing Address - Country:US
Mailing Address - Phone:419-394-8889
Mailing Address - Fax:
Practice Address - Street 1:142 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2312
Practice Address - Country:US
Practice Address - Phone:419-394-5178
Practice Address - Fax:419-394-7648
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0404520Medicaid