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General NPI Number Information
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NPI Number | 1407601164
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Entity Type | Organization
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Legal Business Name | WANDELL DENTAL CORPORATION
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Dates
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Enumeration Date | 04/17/2024
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Last Update Date | 04/17/2024
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Provider Practice Location Address
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Address Line | 620 S DORA ST STE 205
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City | UKIAH
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State | CA
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Zip | 95482-5482
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Country | US
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Telephone | 707-462-6983
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Fax | 707-462-6984
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Provider Business Mailing Address
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Address Line | 620 S DORA ST STE 205
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City | UKIAH
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State | CA
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Zip | 95482-5482
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Country | US
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Telephone | 707-462-6983
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Fax | 707-462-6984
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Authorized Official
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Title or Position | OWNER
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Name | DR. ADAM JOSHUA FARRELL WANDELL
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Credential | DDS, MD
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Telephone | 650-714-3694
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State |
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