Healthcare Provider Details

I. General information

NPI: 1104453075
Provider Name (Legal Business Name): JOHN HARDIE WHEELOCK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10175 GATEWAY BLVD W STE 304
EL PASO TX
79925-2203
US

IV. Provider business mailing address

10175 GATEWAY BLVD W STE 304
EL PASO TX
79925-2203
US

V. Phone/Fax

Practice location:
  • Phone: 915-504-6880
  • Fax: 915-599-8579
Mailing address:
  • Phone: 915-504-6880
  • Fax: 915-599-8579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD011987
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number42189
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: