Healthcare Provider Details

I. General information

NPI: 1598758427
Provider Name (Legal Business Name): SAVANNAH WADDY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E CARSON PLAZA CT 101
CARSON CA
90746-3289
US

IV. Provider business mailing address

520 E CARSON PLAZA CT 101
CARSON CA
90746-3289
US

V. Phone/Fax

Practice location:
  • Phone: 310-323-4543
  • Fax: 310-323-4548
Mailing address:
  • Phone: 310-323-4543
  • Fax: 310-323-4548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberD31136
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: