Healthcare Provider Details

I. General information

NPI: 1104719673
Provider Name (Legal Business Name): MICHAEL ANTHONY WADLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9202 S PENNSYLVANIA AVE
OKLAHOMA CITY OK
73159-6902
US

IV. Provider business mailing address

13204 MAPLEWOOD AVE
OKLAHOMA CITY OK
73120-1880
US

V. Phone/Fax

Practice location:
  • Phone: 405-682-4665
  • Fax:
Mailing address:
  • Phone: 918-630-9211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8056
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: