Healthcare Provider Details

I. General information

NPI: 1174720825
Provider Name (Legal Business Name): HAMMOND SPENCER WADDELL R.D.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 PONCE DE LEON AVE NE
ATLANTA GA
30308-2012
US

IV. Provider business mailing address

1224 SANDEN FERRY DR
DECATUR GA
30033-3346
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-9772
  • Fax:
Mailing address:
  • Phone: 770-696-1067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH006199
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: