Provider Demographics
NPI:1609600238
Name:MORGANTOWN DENTAL GROUP, PLLC
Entity type:Organization
Organization Name:MORGANTOWN DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-292-7307
Mailing Address - Street 1:142 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-5413
Mailing Address - Country:US
Mailing Address - Phone:304-292-7307
Mailing Address - Fax:
Practice Address - Street 1:142 HIGH ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-5413
Practice Address - Country:US
Practice Address - Phone:304-292-7307
Practice Address - Fax:304-292-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty