Provider Demographics
NPI:1043304322
Name:WADDELL, THOMAS GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GREGORY
Last Name:WADDELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:SUITE 356
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-461-1900
Mailing Address - Fax:619-461-6581
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:SUITE 356
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-461-1900
Practice Address - Fax:619-461-6581
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice