Healthcare Provider Details

I. General information

NPI: 1164892329
Provider Name (Legal Business Name): WHEELER FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SW 8TH AVE
MILTON FREEWATER OR
97862-1595
US

IV. Provider business mailing address

1 SW 8TH AVE
MILTON FREEWATER OR
97862-1595
US

V. Phone/Fax

Practice location:
  • Phone: 541-938-7752
  • Fax: 541-938-3093
Mailing address:
  • Phone: 541-938-7752
  • Fax: 541-938-3093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8975
License Number StateOR

VIII. Authorized Official

Name: DR. CARL IVAN WHEELER
Title or Position: OWNER/MANAGER
Credential: DMD
Phone: 541-938-7752