Healthcare Provider Details

I. General information

NPI: 1710376470
Provider Name (Legal Business Name): WEDGEWOOD DENTAL L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 SALEM AVE STE A
ROLLA MO
65401-3444
US

IV. Provider business mailing address

713 SALEM AVE STE A
ROLLA MO
65401-3444
US

V. Phone/Fax

Practice location:
  • Phone: 573-368-7325
  • Fax: 573-364-7326
Mailing address:
  • Phone: 573-368-7325
  • Fax: 573-364-7326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number015865
License Number StateMO

VIII. Authorized Official

Name: DR. :LINDA KAY WESTMORELAND
Title or Position: OWNER
Credential: D.D.S.
Phone: 573-368-7325