Provider Demographics
NPI:1871772814
Name:DR JAY B WETTSTEIN DMD PC
Entity type:Organization
Organization Name:DR JAY B WETTSTEIN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:WETTSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-889-6666
Mailing Address - Street 1:478 SW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914
Mailing Address - Country:US
Mailing Address - Phone:541-889-6666
Mailing Address - Fax:541-889-2904
Practice Address - Street 1:478 SW 12TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914
Practice Address - Country:US
Practice Address - Phone:541-889-6666
Practice Address - Fax:541-889-2904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7219122300000X
ORD8990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804186800Medicaid
OR209473Medicaid