Healthcare Provider Details

I. General information

NPI: 1740694181
Provider Name (Legal Business Name): WAFELBAKKER ANDERSON ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 SAN MIGUEL DR STE 33
WALNUT CREEK CA
94596-5279
US

IV. Provider business mailing address

1855 SAN MIGUEL DR STE 33
WALNUT CREEK CA
94596-5279
US

V. Phone/Fax

Practice location:
  • Phone: 925-935-5630
  • Fax: 925-934-8130
Mailing address:
  • Phone: 925-935-5630
  • Fax: 925-934-8130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. BAS WILLEM WAFELBAKKER
Title or Position: PRESIDENT
Credential: DMD
Phone: 925-935-5630