Healthcare Provider Details

I. General information

NPI: 1558561548
Provider Name (Legal Business Name): JEFFREY RYAN WESSEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 ADMIRAL TAUSSIG BLVD
NORFOLK VA
23511
US

IV. Provider business mailing address

1647 ADMIRAL TAUSSIG BLVD
NORFOLK VA
23511
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-8547
  • Fax:
Mailing address:
  • Phone: 757-953-8547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30-022511
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: