Healthcare Provider Details

I. General information

NPI: 1568804961
Provider Name (Legal Business Name): MATTHEW THOMAS WENDAHL DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19045 E VALLEY VIEW PKWY
INDEPENDENCE MO
64055-7030
US

IV. Provider business mailing address

12 E 54TH TER
KANSAS CITY MO
64112-2858
US

V. Phone/Fax

Practice location:
  • Phone: 800-566-2079
  • Fax:
Mailing address:
  • Phone: 610-248-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10313
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number61841
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2022006316
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: