Healthcare Provider Details

I. General information

NPI: 1285806810
Provider Name (Legal Business Name): WENDELL WAYNE NEELEY II DMD, MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

706 DELAWARE ST
SHREVEPORT LA
71106-1640
US

V. Phone/Fax

Practice location:
  • Phone: 318-813-2625
  • Fax:
Mailing address:
  • Phone: 210-378-2475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS-800
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20792
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: